Provider Demographics
NPI:1174558688
Name:MONTICELLO DRUGS, INC
Entity type:Organization
Organization Name:MONTICELLO DRUGS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:MR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:R
Authorized Official - Last Name:WOODRUFF
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:217-762-3176
Mailing Address - Street 1:109 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:IL
Mailing Address - Zip Code:61856-1967
Mailing Address - Country:US
Mailing Address - Phone:217-762-3176
Mailing Address - Fax:217-762-2330
Practice Address - Street 1:109 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:IL
Practice Address - Zip Code:61856-1967
Practice Address - Country:US
Practice Address - Phone:217-762-3176
Practice Address - Fax:217-762-2330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL18710433332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
1452921OtherNABP
1452921OtherNABP
0821140001Medicare NSC