Organization
WAUCONDA PHARMACY INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
TERRY BRUNER RPH (OWNER)
(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
222 S MAIN ST, WAUCONDA, IL 60084-1828
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
—
—
3336C0004X
Compounding Pharmacy
Primary
054006291
IL
3336H0001X
Home Infusion Therapy Pharmacy
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1428196
BCBS PHARMACY
IL
01
—
1428196
OTHER ID NUMBER
—
05
—
362686883001
—
IL
01
—
IL3147
MEDICARE PART B
IL
Enumeration date
10/25/2006
Last updated
11/07/2011
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