Petersburg Pharmacy, Inc

Primary specialty

Community/Retail PharmacyTaxonomy code 3336C0003X

License

054.015430 Issued in IL

Legal business name

PETERSBURG PHARMACY, INC

Practice address

1 Centre Dr
Suite 100
Petersburg, IL 62675-9467

Phone

(217) 632-7777

Fax

(217) 632-7618

NPI assigned

Oct 13, 2006

Last updated

Jun 2, 2015By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mr. David Bagot, RPHNPI 1285213983

Title

Pharmacist/Owner

Phone

(217) 632-7777

Specialties & licenses 1

Addresses

Other identifiers 5

Medicare fee-for-service enrollment

Enrolled in IL2 enrollments

Enrollment records 2

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Medicare medical equipment & supply locations

Locations

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• David Bagot, RPH

  • Pharmacist
  • Petersburg, IL
  • NPI 1285213983
  NPD Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1160697600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1433203200000",
    "number": "1538259403",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1 CENTRE DR",
            "address_2": "SUITE 100",
            "city": "PETERSBURG",
            "state": "IL",
            "postal_code": "626759467",
            "telephone_number": "217-632-7777",
            "fax_number": "217-632-7618"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1 CENTRE DR",
            "address_2": "SUITE 100",
            "city": "PETERSBURG",
            "state": "IL",
            "postal_code": "626759467",
            "telephone_number": "217-632-7777",
            "fax_number": "217-632-7618"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PETERSBURG PHARMACY, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-10-13",
        "last_updated": "2015-06-02",
        "status": "A",
        "authorized_official_last_name": "BAGOT",
        "authorized_official_first_name": "DAVID",
        "authorized_official_title_or_position": "PHARMACIST/OWNER",
        "authorized_official_telephone_number": "217-632-7777",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "RPH"
    },
    "taxonomies": [
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "IL",
            "license": "054.015430",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CONTROLLED SUB LIC #",
            "identifier": "320.008365",
            "state": "IL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDCO PROVIDER NUMBER",
            "identifier": "120007769",
            "state": "IL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DIV 1 PHARMACY LICENSE",
            "identifier": "054.015430",
            "state": "IL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NABP NUMBER",
            "identifier": "1477745",
            "state": "IL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "STATE ID NUMBER",
            "identifier": "3574-5932",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Menard Medical Center, LLC
• Tracy Ann Muller, MS SLP CCC
• Clara Munyer, SLP-CCC
• David D Newton, M.D.
• Dana Yvette Ogle, PTA
• Petersburg Spine & Sport Inc (Petersburg Spine & Sport)
• Porta Comm. Unit District 202
• Potter Pharmacy Inc (Potter Drug Inc)
• Emilie J Redding, M.D.
• Delores J Ring, LCPC

• Community/Retail Pharmacy in Petersburg, IL
• Providers in Petersburg, IL by specialty
• Community/Retail Pharmacy in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 2, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.