Provider Demographics
NPI:1487720140
Name:AMICARE PHARMACY, INC
Entity type:Organization
Organization Name:AMICARE PHARMACY, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:MERIDETH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:309-517-6710
Mailing Address - Street 1:4101 JOHN DEERE RD
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6790
Mailing Address - Country:US
Mailing Address - Phone:309-517-6710
Mailing Address - Fax:309-517-6708
Practice Address - Street 1:4101 JOHN DEERE RD
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6790
Practice Address - Country:US
Practice Address - Phone:309-517-6710
Practice Address - Fax:309-517-6708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL203001033332B00000X
IL0540136723336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0113120Medicaid
2021706OtherPK
IL363807756001Medicaid
IA0113120Medicaid