Provider Demographics
NPI:1487766341
Name:PHARMAX INC.
Entity type:Organization
Organization Name:PHARMAX INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:T
Authorized Official - Last Name:MCINTOSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-954-5510
Mailing Address - Street 1:1221 CHARLESTON AVE
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-4130
Mailing Address - Country:US
Mailing Address - Phone:217-234-8881
Mailing Address - Fax:217-234-8885
Practice Address - Street 1:1221 CHARLESTON AVE
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-4130
Practice Address - Country:US
Practice Address - Phone:217-234-8881
Practice Address - Fax:217-234-8885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0510300673336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1455927OtherNCPDP #
IL1455927OtherNCPDP #
IL=========912Medicaid
ILBM7413127OtherDEA #