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
—
—
3336C0003X
Community/Retail Pharmacy
Primary
54.015385
IL
3336L0003X
Long Term Care Pharmacy
—
—
3336M0003X
Managed Care Organization Pharmacy
—
—
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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