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Organization
LAKE OF DECATUR INC
Active
Organization
LAKE OF DECATUR INC
Active
Other names
DALES SOUTHLAKE PHARMACY
Organization subpart
No
Provider details
NPI number
Authorized official
DALE COLEE (PRESIDENT)
(217) 429-5165
Entity
Organization
Contact information
Practice address
245 W 1ST DR STE B, DECATUR, IL 62521-5381
(217) 429-5165
(217) 429-5172
Mailing address
245 W 1ST DR STE B, DECATUR, IL 62521-5381
(217) 429-5165
(217) 429-5172
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
—
NULL
3336C0003X
Community/Retail Pharmacy
Primary
54.015385
IL
3336L0003X
Long Term Care Pharmacy
—
NULL
3336M0003X
Managed Care Organization Pharmacy
—
NULL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2021672
PK
—
Enumeration date
05/09/2006
Last updated
10/21/2021
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