Provider Demographics
NPI:1356561039
Name:ILLINI CLINIC PHARMACY INC
Entity type:Organization
Organization Name:ILLINI CLINIC PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:R
Authorized Official - Last Name:MERIDETH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:309-792-7002
Mailing Address - Street 1:855 ILLINI DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SILVIS
Mailing Address - State:IL
Mailing Address - Zip Code:61282-2907
Mailing Address - Country:US
Mailing Address - Phone:309-792-7002
Mailing Address - Fax:309-792-7003
Practice Address - Street 1:855 ILLINI DR
Practice Address - Street 2:SUITE 200
Practice Address - City:SILVIS
Practice Address - State:IL
Practice Address - Zip Code:61282-2907
Practice Address - Country:US
Practice Address - Phone:309-792-7002
Practice Address - Fax:309-792-7003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336L0003X
IL0540138073336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL1258590001Medicare ID - Type Unspecified