Provider Demographics
NPI:1457362956
Name:PRESCRIPTION SHOPPE OF CLINTON INC
Entity Type:Organization
Organization Name:PRESCRIPTION SHOPPE OF CLINTON INC
Other - Org Name:PRESCRIPTION SHOPPE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:HIMSTEDT
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:217-935-8333
Mailing Address - Street 1:211 W VAN BUREN ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:IL
Mailing Address - Zip Code:61727-2235
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:211 W VAN BUREN ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:IL
Practice Address - Zip Code:61727-2235
Practice Address - Country:US
Practice Address - Phone:217-935-8333
Practice Address - Fax:217-935-6243
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
IL333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Not Answered333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1431181OtherOTHER ID NUMBER-COMMERCIAL NUMBER
IL=========001Medicaid
IL=========001Medicaid