# PETERSBURG PHARMACY, INC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1538259403
- **Authorized official:** MR. DAVID BAGOT RPH (PHARMACIST/OWNER)
- **Authorized official phone:** (217) 632-7777

## Contact information

- **Practice address:** 1 CENTRE DR, SUITE 100, PETERSBURG, IL 62675-9467
- **Practice address phone:** (217) 632-7777
- **Practice address fax:** (217) 632-7618
- **Mailing address:** 1 CENTRE DR, SUITE 100, PETERSBURG, IL 62675-9467
- **Mailing address phone:** (217) 632-7777
- **Mailing address fax:** (217) 632-7618

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 3336C0003X | Community/Retail Pharmacy | 054.015430 | IL | Yes |

## Other

- **Enumeration date:** 10/13/2006
- **Last updated:** 06/02/2015

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 054.015430 | DIV 1 PHARMACY LICENSE | IL |
| 01 | — | 120007769 | MEDCO PROVIDER NUMBER | IL |
| 01 | — | 1477745 | NABP NUMBER | IL |
| 01 | — | 320.008365 | CONTROLLED SUB LIC \# | IL |
| 01 | — | 3574-5932 | STATE ID NUMBER | IL |