Provider Demographics
NPI:1871110254
Name:ILLINI CLINIC PHARMACY INC
Entity type:Organization
Organization Name:ILLINI CLINIC PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:MERIDETH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-781-5770
Mailing Address - Street 1:855 ILLINI DR STE 200
Mailing Address - Street 2:
Mailing Address - City:SILVIS
Mailing Address - State:IL
Mailing Address - Zip Code:61282-2908
Mailing Address - Country:US
Mailing Address - Phone:093-792-7002
Mailing Address - Fax:
Practice Address - Street 1:103 N PROSPECT ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:IL
Practice Address - Zip Code:61238-1148
Practice Address - Country:US
Practice Address - Phone:309-781-5770
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-01
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL054-021593OtherSTATE LICENSE
IL320-013281OtherCONTROLLED SUBSTANCE LICENSE