Basic Information
| Provider Information | |||||||||
| NPI: | 1063473148 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PINCKNEYVILLE COMMUNITY HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | PINCKNEYVILLE COMMUNITY HOSPITAL PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 5383 STATE ROUTE 154 | ||||||||
| Address2: | |||||||||
| City: | PINCKNEYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622743342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183572187 | ||||||||
| FaxNumber: | 6183578888 | ||||||||
| Practice Location | |||||||||
| Address1: | 5383 STATE ROUTE 154 | ||||||||
| Address2: | |||||||||
| City: | PINCKNEYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622743342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183572187 | ||||||||
| FaxNumber: | 6183578888 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2006 | ||||||||
| LastUpdateDate: | 01/26/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CARSON | ||||||||
| AuthorizedOfficialFirstName: | KARA | ||||||||
| AuthorizedOfficialMiddleName: | JO | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6183575902 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PINCKNEYVILLE COMMUNITY HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MACC, CPA, CHFP | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | Y | Suppliers | Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 1454127 | 01 | IL | NABP | OTHER | 141307 | 01 | MEDICARE | OTHER |