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Provider Information for 1114095320


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RENES DRUG STORE INC

Organization Subpart: NO

NPI: 1114095320
Last Updated: 2010-12-14
Certification Date:

Details

NameValue
NPI1114095320
Enumeration Date2006-12-04
NPI TypeNPI-2 Organization
StatusActive
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
 
Secondary Practice Address(es)
Health Information Exchange
Endpoint TypeEndpointEndpoint DescriptionUseContent TypeAffiliationEndpoint Location
Other Identifiers
IssuerStateNumberOther Issuer
MEDICAIDIL=========6256801
Taxonomy
Primary TaxonomySelected TaxonomyStateLicense Number
Yes 333600000X - Pharmacy IL054005099