Basic Information
Provider Information | |||||||||
NPI: | 1063767424 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SOUTHERN ILLINOIS HEALTHCARE FOUNDATION, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | WEBER MEDICAL CLINIC PHARMACY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2041 GOOSE LAKE RD | ||||||||
Address2: |   | ||||||||
City: | SAUGET | ||||||||
State: | IL | ||||||||
PostalCode: | 622062822 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6183320953 | ||||||||
FaxNumber: | 6183322487 | ||||||||
Practice Location | |||||||||
Address1: | 1200 N EAST ST | ||||||||
Address2: |   | ||||||||
City: | OLNEY | ||||||||
State: | IL | ||||||||
PostalCode: | 624502432 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6183958561 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/20/2012 | ||||||||
LastUpdateDate: | 01/17/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MCCULLEY | ||||||||
AuthorizedOfficialFirstName: | LARRY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 6183320694 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | 054017914 | IL | Y |   | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
ID | Type | State | Issuer | Description | 1487164 | 01 | IL | NCPDP | OTHER | IL7545 | 01 | IL | WPS MEDICARE PART B | OTHER |