Organization
WAUCONDA PHARMACY, INC.
Active
Other names
VITAL CARE OF WAUCONDA
Organization subpart
No
Provider details
NPI number
Authorized official
TERRY J BRUNER (MANAGER)
(847) 526-2591
Entity
Organization
Contact information
Practice address
222 S MAIN ST, WAUCONDA, IL 60084-1828
(847) 526-2591
(847) 526-1598
Mailing address
PO BOX 5047, MERIDIAN, MS 39302-5047
(800) 447-4095
(601) 482-7490
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
Primary
054-006291
IL
332BC3200X
Customized Equipment (DME)
054-006291
IL
332BP3500X
Parenteral & Enteral Nutrition Supplies (DME)
054-006291
IL
332BX2000X
Oxygen Equipment & Supplies (DME)
054-006291
IL
333600000X
Pharmacy
054-006291
IL
3336C0003X
Community/Retail Pharmacy
054-006291
IL
3336H0001X
Home Infusion Therapy Pharmacy
054-006291
IL
3336L0003X
Long Term Care Pharmacy
054-006291
IL
3336M0002X
Mail Order Pharmacy
054-006291
IL
3336S0011X
Specialty Pharmacy
054-006291
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1428196
BCBS PHARMACY
IL
05
—
36368683001
—
IL
01
—
IL3147
MEDICARE PART B
IL
Enumeration date
08/30/2006
Last updated
11/07/2011
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