Healthcare Provider Details

I. General information

NPI: 1770589210
Provider Name (Legal Business Name): FAMILY PHARMACY OF COLLINSVILLE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

228 W MAIN ST
COLLINSVILLE IL
62234-3016
US

IV. Provider business mailing address

228 W MAIN ST
COLLINSVILLE IL
62234-3016
US

V. Phone/Fax

Practice location:
  • Phone: 618-345-2880
  • Fax: 618-345-0899
Mailing address:
  • Phone: 618-345-2880
  • Fax: 618-345-0899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number StateIL

VIII. Authorized Official

Name: JUDITH L WEISS
Title or Position: CHIEF PHARMACIST/PRESIDENT
Credential: RPH
Phone: 618-345-2880