Healthcare Provider Details

I. General information

NPI: 1003980111
Provider Name (Legal Business Name): MARISSA FOOD MART
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 04/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 E. LYONS ST.
MARISSA IL
62257
US

IV. Provider business mailing address

700 E. LYONS ST.
MARISSA IL
62257
US

V. Phone/Fax

Practice location:
  • Phone: 618-295-2317
  • Fax: 618-295-2318
Mailing address:
  • Phone: 618-295-2317
  • Fax: 618-295-2318

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number054.009766
License Number StateIL

VIII. Authorized Official

Name: MRS. GAIL LASKOWSKI
Title or Position: SECRETARY OF CORP.
Credential:
Phone: 618-295-2317