Provider Demographics
NPI:1902918840
Name:COPPER BEND PHARMACY, INC
Entity Type:Organization
Organization Name:COPPER BEND PHARMACY, INC
Other - Org Name:COPPER BEND PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:CLEMENT
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:618-234-7181
Mailing Address - Street 1:2900 FRANK SCOTT PKWY W
Mailing Address - Street 2:STE 920-B
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223-8509
Mailing Address - Country:US
Mailing Address - Phone:618-234-7181
Mailing Address - Fax:618-234-9811
Practice Address - Street 1:2900 FRANK SCOTT PKWY W
Practice Address - Street 2:STE 920-B
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62223-5000
Practice Address - Country:US
Practice Address - Phone:618-234-7181
Practice Address - Fax:618-234-9811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
IL0540084303336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2018496OtherPK
IL=========001Medicaid
IL=========001Medicaid