Basic Information
| Provider Information | |||||||||
| NPI: | 1689761223 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRAIRIE ONCOLOGY MANAGEMENT SERVICES PHARMACY | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 210 W MCKINLEY AVE STE 1 | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 625265858 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173293239 | ||||||||
| FaxNumber: | 2178769829 | ||||||||
| Practice Location | |||||||||
| Address1: | 210 W MCKINLEY AVE | ||||||||
| Address2: | STE 1 | ||||||||
| City: | DECATUR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 625265858 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173293239 | ||||||||
| FaxNumber: | 2178769829 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2006 | ||||||||
| LastUpdateDate: | 03/28/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BENNETT | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | REGISTERED PHARMACIST | ||||||||
| AuthorizedOfficialTelephone: | 2173293239 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | R.PH. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 054014168 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Pharmacy Service Providers | Pharmacist |
No ID Information.