Healthcare Provider Details

I. General information

NPI: 1164472304
Provider Name (Legal Business Name): ALTAMONT PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 08/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 N 3RD ST
ALTAMONT IL
62411-1408
US

IV. Provider business mailing address

12 N 3RD ST
ALTAMONT IL
62411-1408
US

V. Phone/Fax

Practice location:
  • Phone: 618-483-5614
  • Fax: 618-483-3425
Mailing address:
  • Phone: 618-483-5614
  • Fax: 618-483-3425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number054008775
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number054008775
License Number StateIL

VIII. Authorized Official

Name: DOUG PHILLIPS
Title or Position: PRESIDENT
Credential:
Phone: 618-483-5614