Healthcare Provider Details

I. General information

NPI: 1417947870
Provider Name (Legal Business Name): HERRIN DRUG INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2005
Last Update Date: 11/24/2020
Certification Date: 11/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 N PARK AVE
HERRIN IL
62948-3148
US

IV. Provider business mailing address

116 N PARK AVE
HERRIN IL
62948-3148
US

V. Phone/Fax

Practice location:
  • Phone: 618-942-5315
  • Fax: 618-942-4584
Mailing address:
  • Phone: 618-942-5315
  • Fax: 618-942-4584

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number054007687
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. DAVID ALLEN MATTINGLY
Title or Position: PRESIDENT/PHARMACIST
Credential: R.PH.
Phone: 618-942-5315