Provider Information for 1114095320
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RENES DRUG STORE INC
Organization Subpart: NO
NPI: 1114095320
Last Updated: 2010-12-14
Certification Date:
Certification Date:
Details
Name | Value | ||||||||
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NPI | 1114095320 | ||||||||
Enumeration Date | 2006-12-04 | ||||||||
NPI Type | NPI-2 Organization | ||||||||
Status | Active | ||||||||
Authorized Official Information | Name: Mr. GORDON JOHN MAZZOTTI Licensed Registered Title: President Chief Executive Officer Phone: 2178243533 | ||||||||
Mailing Address | 201 WEST MAIN CROSS TAYLORVILLE, IL 62568-2247 United States Phone: 217-824-3533 | Fax:217-824-3492 | ||||||||
Primary Practice Address | 201 WEST MAIN CROSS TAYLORVILLE, IL 62568-2247 United States Phone: 217-824-3533 | Fax:217-824-3492 | ||||||||
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