Healthcare Provider Details

I. General information

NPI: 1124064035
Provider Name (Legal Business Name): SOUTHERN ILLINOIS UNIVERSITY STUDENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 04/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

374 E GRAND AVE
CARBONDALE IL
62901-3962
US

IV. Provider business mailing address

374 E GRAND AVE
CARBONDALE IL
62901-3962
US

V. Phone/Fax

Practice location:
  • Phone: 618-453-4417
  • Fax: 618-453-4672
Mailing address:
  • Phone: 618-453-4417
  • Fax: 618-453-4672

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336I0012X
TaxonomyInstitutional Pharmacy
License Number054.017089
License Number StateIL

VIII. Authorized Official

Name: SUSAN CHANEY
Title or Position: PHARMACY DIRECTOR
Credential: RPH
Phone: 618-453-4417