Provider Demographics
NPI:1548314990
Name:BARNATO PHARMACY OF PEORIA LLC
Entity type:Organization
Organization Name:BARNATO PHARMACY OF PEORIA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:BARNATO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-689-9999
Mailing Address - Street 1:5001 N BIG HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-3538
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5001 N BIG HOLLOW RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-3538
Practice Address - Country:US
Practice Address - Phone:309-689-9999
Practice Address - Fax:309-692-9033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IL0540091433336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2019222OtherPK
IL371207012002Medicaid
IL371207012002Medicaid