| Organization Name: | WAUCONDA PHARMACY, INC. |
| NPI Number: | 1568571420 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | TERRY J BRUNER (MANAGER) |
| Mailing Address: | 222 S Main St Wauconda |
| State: | IL US |
| Postal Code: | 600841828 |
| Phone Number: | 8475262591 |
| Fax Number: | 8475261598 |
| NPI Enumeration Date: | 08/30/2006 |
| NPI Last Update Date: | 11/07/2011 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 332BC3200X |
| License Number: | 054-006291 |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | IL |
| Taxonomy Type: | Suppliers |
| Taxonomy Classification: | Durable Medical Equipment & Medical Supplies |
| Taxonomy Specialization: | Customized Equipment |
| Taxonomy Definition: | |