Basic Information
Provider Information | |||||||||
NPI: | 1376659029 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GRAHAM HOSPITAL ASSOCIATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 210 W WALNUT ST | ||||||||
Address2: |   | ||||||||
City: | CANTON | ||||||||
State: | IL | ||||||||
PostalCode: | 615202444 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3096475240 | ||||||||
FaxNumber: | 3096495110 | ||||||||
Practice Location | |||||||||
Address1: | 210 W WALNUT ST | ||||||||
Address2: |   | ||||||||
City: | CANTON | ||||||||
State: | IL | ||||||||
PostalCode: | 615202444 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3096475240 | ||||||||
FaxNumber: | 3096495110 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/22/2006 | ||||||||
LastUpdateDate: | 09/09/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | REEDER | ||||||||
AuthorizedOfficialFirstName: | JULIE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VP OF FINANCE/CFO | ||||||||
AuthorizedOfficialTelephone: | 3096475240 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336L0003X |   |   | N |   | Suppliers | Pharmacy | Long Term Care Pharmacy | 3336I0012X | 059.003399 | IL | Y |   | Suppliers | Pharmacy | Institutional Pharmacy |
ID Information
ID | Type | State | Issuer | Description | 1433258 | 01 | IL | NABP NUMBER | OTHER |