Provider Demographics
NPI:1720356421
Name:KEWANEE HOSPITAL PHARMACY
Entity Type:Organization
Organization Name:KEWANEE HOSPITAL PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHEIF EXECUTIVE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARGARET
Authorized Official - Middle Name:
Authorized Official - Last Name:GUSTAFSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-852-7520
Mailing Address - Street 1:1051 WEST SOUTH STREET
Mailing Address - Street 2:P O BOX 747
Mailing Address - City:KEWANEE
Mailing Address - State:IL
Mailing Address - Zip Code:61443-0747
Mailing Address - Country:US
Mailing Address - Phone:309-852-7890
Mailing Address - Fax:
Practice Address - Street 1:1051 W SOUTH ST
Practice Address - Street 2:
Practice Address - City:KEWANEE
Practice Address - State:IL
Practice Address - Zip Code:61443-8354
Practice Address - Country:US
Practice Address - Phone:309-852-7890
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KEWANEE HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-12-08
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL054017368333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy