# THE CARBONDALE CLINIC PHARMACY

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- **Entity:** Organization
- **Status:** Active
- **Parent organization:** THE CARBONDALE CLINIC, S.C.
- **Organization subpart:** Yes

## Provider details

- **NPI number:** 1710043435
- **Legal business name:** THE CARBONDALE CLINIC, S.C.
- **Authorized official:** MR. ALLAN NORMAN (CEO)
- **Authorized official phone:** (618) 549-5361

## Contact information

- **Practice address:** 2601 W MAIN ST, SUITE 101, CARBONDALE, IL 62901-1031
- **Practice address phone:** (618) 549-5361
- **Practice address fax:** (618) 549-5158
- **Mailing address:** 2601 W MAIN ST, SUITE 101, CARBONDALE, IL 62901-1031
- **Mailing address phone:** (618) 549-5361
- **Mailing address fax:** (618) 549-5158

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 183500000X | Pharmacist | 051-023018 | IL | — |
| 183500000X | Pharmacist | 051-034485 | IL | — |
| 183700000X | Pharmacy Technician | 049-083922 | IL | — |
| 183700000X | Pharmacy Technician | 049-127699 | IL | — |
| 183700000X | Pharmacy Technician | 049-156580 | IL | — |
| 183700000X | Pharmacy Technician | 049-169519 | IL | — |
| 183700000X | Pharmacy Technician | 049-173061 | IL | — |
| 3336C0003X | Community/Retail Pharmacy | 0054-009512 | IL | Yes |

## Other

- **Enumeration date:** 12/28/2006
- **Last updated:** 04/30/2008

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 1296860001 | MEDICARE LEGACY | IL |
| 01 | — | 1454014 | NABP | IL |