Provider Demographics
NPI:1912966953
Name:GRUNDY COUNTY DRUG CO INC
Entity Type:Organization
Organization Name:GRUNDY COUNTY DRUG CO INC
Other - Org Name:MORRIS HEALTHMART MORRIS FAMILY DISCOUT DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:FUNK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:815-942-3662
Mailing Address - Street 1:2405 SYCAMORE DR
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:IL
Mailing Address - Zip Code:60450-1020
Mailing Address - Country:US
Mailing Address - Phone:815-942-3660
Mailing Address - Fax:815-942-3641
Practice Address - Street 1:2405 SYCAMORE DR
Practice Address - Street 2:
Practice Address - City:MORRIS
Practice Address - State:IL
Practice Address - Zip Code:60450-1020
Practice Address - Country:US
Practice Address - Phone:815-942-3660
Practice Address - Fax:815-942-3641
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-20
Last Update Date:2011-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL203000611332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3221299OtherBLUE CROSS BLUE SHIELD
IL=========002Medicaid
IL3221299OtherBLUE CROSS BLUE SHIELD
1033950001Medicare ID - Type Unspecified