Organization
PROFESIONAL PHARMACY MANAGERS LLC
Active
Other names
GRANVILLE DRUG
Organization subpart
No
Provider details
NPI number
Authorized official
DAVID TYNER (OWNER)
(815) 853-4342
Entity
Organization
Contact information
Practice address
314 S MCCOY ST, GRANVILLE, IL 61326-9333
(815) 339-2286
(815) 339-2288
Mailing address
PO BOX 340, GRANVILLE, IL 61326-0340
Taxonomy
Speciality
Code
Description
License number
State
3336C0003X
Community/Retail Pharmacy
Primary
054017877
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1410567
NCPDP PROVIDER IDENTIFICATION NUMBER
—
Enumeration date
12/09/2005
Last updated
03/27/2012
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