Healthcare Provider Details

I. General information

NPI: 1801760012
Provider Name (Legal Business Name): SOUTHERN ILLINOIS HEALTH CARE FOUNDATION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2025
Last Update Date: 10/07/2025
Certification Date: 10/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 S 3RD ST STE 100
BELLEVILLE IL
62220-1952
US

IV. Provider business mailing address

180 S 3RD ST STE 100
BELLEVILLE IL
62220-1952
US

V. Phone/Fax

Practice location:
  • Phone: 618-332-0694
  • Fax:
Mailing address:
  • Phone: 618-332-0694
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. LARRY MCCULLEY
Title or Position: CEO
Credential:
Phone: 618-332-0694