Provider Demographics
NPI:1831274513
Name:WAUCONDA PHARMACY INC
Entity type:Organization
Organization Name:WAUCONDA PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUNER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:847-526-2591
Mailing Address - Street 1:222 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WAUCONDA
Mailing Address - State:IL
Mailing Address - Zip Code:60084-1828
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:222 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WAUCONDA
Practice Address - State:IL
Practice Address - Zip Code:60084-1828
Practice Address - Country:US
Practice Address - Phone:847-526-2591
Practice Address - Fax:847-526-1598
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2011-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336H0001X, 332B00000X, 3336C0003X, 333600000X
IL0540062913336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1428196OtherBCBS PHARMACY
ILIL3147OtherMEDICARE PART B
1428196OtherOTHER ID NUMBER
IL362686883001Medicaid
1428196OtherOTHER ID NUMBER