Basic Information
| Provider Information | |||||||||
| NPI: | 1710043435 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE CARBONDALE CLINIC PHARMACY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2601 W MAIN ST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | CARBONDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629011031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185495361 | ||||||||
| FaxNumber: | 6185495158 | ||||||||
| Practice Location | |||||||||
| Address1: | 2601 W MAIN ST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | CARBONDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629011031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185495361 | ||||||||
| FaxNumber: | 6185495158 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2006 | ||||||||
| LastUpdateDate: | 04/30/2008 | ||||||||
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| AuthorizedOfficialLastName: | NORMAN | ||||||||
| AuthorizedOfficialFirstName: | ALLAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6185495361 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | THE CARBONDALE CLINIC, S.C. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 051-034485 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Pharmacy Service Providers | Pharmacist | 183500000X | 051-023018 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Pharmacy Service Providers | Pharmacist | 183700000X | 049-083922 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Pharmacy Service Providers | Pharmacy Technician | 183700000X | 049-127699 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Pharmacy Service Providers | Pharmacy Technician | 183700000X | 049-173061 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Pharmacy Service Providers | Pharmacy Technician | 183700000X | 049-156580 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Pharmacy Service Providers | Pharmacy Technician | 183700000X | 049-169519 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Pharmacy Service Providers | Pharmacy Technician | 3336C0003X | 0054-009512 | IL | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 1454014 | 01 | IL | NABP | OTHER | 1296860001 | 01 | IL | MEDICARE LEGACY | OTHER |