Healthcare Provider Details

I. General information

NPI: 1518970128
Provider Name (Legal Business Name): GODFREY PRESCRIPTION SHOPPE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 01/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5701 GODFREY RD
GODFREY IL
62035-2471
US

IV. Provider business mailing address

5701 GODFREY RD
GODFREY IL
62035-2471
US

V. Phone/Fax

Practice location:
  • Phone: 618-466-5577
  • Fax: 618-466-5577
Mailing address:
  • Phone: 618-466-5577
  • Fax: 618-466-5577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number StateIL

VIII. Authorized Official

Name: MR. GERRY EUGENE LECLAIRE
Title or Position: OWNER
Credential: R.PH.
Phone: 618-466-5577