Provider Demographics
NPI:1932208907
Name:JOHN'S PHARMACY INC
Entity Type:Organization
Organization Name:JOHN'S PHARMACY INC
Other - Org Name:THE SULLIVAN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TONY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:217-728-2331
Mailing Address - Street 1:102 E HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:SULLIVAN
Mailing Address - State:IL
Mailing Address - Zip Code:61951-2002
Mailing Address - Country:US
Mailing Address - Phone:217-728-2331
Mailing Address - Fax:217-728-2223
Practice Address - Street 1:102 E HARRISON ST
Practice Address - Street 2:
Practice Address - City:SULLIVAN
Practice Address - State:IL
Practice Address - Zip Code:61951-2002
Practice Address - Country:US
Practice Address - Phone:217-728-2331
Practice Address - Fax:217-728-2223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2014-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL054-0133673336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1405213OtherNCPDP (NABP) #
IL1405213OtherNCPDP (NABP) #
IL=========001Medicaid