Provider Demographics
NPI:1871546432
Name:AMERICAN PHARMACY OF IL INC
Entity type:Organization
Organization Name:AMERICAN PHARMACY OF IL INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:W
Authorized Official - Last Name:MINESINGER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:309-676-6333
Mailing Address - Street 1:311 N WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61604
Mailing Address - Country:US
Mailing Address - Phone:309-676-6333
Mailing Address - Fax:309-676-1928
Practice Address - Street 1:311 N WESTERN AVE
Practice Address - Street 2:
Practice Address - City:WEST PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61604-5638
Practice Address - Country:US
Practice Address - Phone:309-676-6333
Practice Address - Fax:309-676-1928
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051035850333600000X
ILFA02122373336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========001Medicaid