Provider Demographics
NPI:1841336450
Name:ANTONACCI INC
Entity type:Organization
Organization Name:ANTONACCI INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST AND PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:ANTONACCI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:309-685-5939
Mailing Address - Street 1:4410 N KNOXVILLE AVE
Mailing Address - Street 2:STE A
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-6086
Mailing Address - Country:US
Mailing Address - Phone:309-685-5939
Mailing Address - Fax:309-685-5930
Practice Address - Street 1:4410 N KNOXVILLE AVE
Practice Address - Street 2:STE A
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-6086
Practice Address - Country:US
Practice Address - Phone:309-685-5939
Practice Address - Fax:309-685-5930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2010-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
IL0540091353336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1454545OtherNCPDP PROVIDER IDENTIFICATION NUMBER
IL=========0002Medicaid
IL=========0002Medicaid