Provider Demographics
NPI:1881808137
Name:BRANDT PHARMACY INC
Entity type:Organization
Organization Name:BRANDT PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGR
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:COURTNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-568-7331
Mailing Address - Street 1:101 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:MARENGO
Mailing Address - State:IL
Mailing Address - Zip Code:60152-2217
Mailing Address - Country:US
Mailing Address - Phone:815-568-7242
Mailing Address - Fax:815-568-0428
Practice Address - Street 1:101 N STATE ST
Practice Address - Street 2:
Practice Address - City:MARENGO
Practice Address - State:IL
Practice Address - Zip Code:60152-2217
Practice Address - Country:US
Practice Address - Phone:815-568-7242
Practice Address - Fax:815-568-0428
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2018-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IL0540043733336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2022580OtherPK
IL=========001Medicaid
0213290001Medicare NSC