Provider Demographics
NPI:1871086082
Name:MEDICATE PHARMACY INC
Entity type:Organization
Organization Name:MEDICATE PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:SCHALTENBRAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-875-1000
Mailing Address - Street 1:1833 KINGSHIGHWAY
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON PARK
Mailing Address - State:IL
Mailing Address - Zip Code:62204
Mailing Address - Country:US
Mailing Address - Phone:618-874-3000
Mailing Address - Fax:618-874-3103
Practice Address - Street 1:5869 BOND AVE
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:IL
Practice Address - Zip Code:62207-2300
Practice Address - Country:US
Practice Address - Phone:618-857-2608
Practice Address - Fax:618-857-2610
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL054-0187363336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL054-018736OtherILLINOIS PHARMACY LICENSE NUMBER
ILCO014205OtherCONTROLLED SUBSTANCE LICENSE NUMBER
ILFM4843606OtherDEA LICENSE NUMBER