Healthcare Provider Details

I. General information

NPI: 1326082173
Provider Name (Legal Business Name): MARYVILLE PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 N CENTER ST
MARYVILLE IL
62062-5624
US

IV. Provider business mailing address

2700 N CENTER ST
MARYVILLE IL
62062-5624
US

V. Phone/Fax

Practice location:
  • Phone: 618-288-7474
  • Fax: 618-288-1860
Mailing address:
  • Phone: 618-288-7474
  • Fax: 618-288-1860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number
License Number StateIL

VIII. Authorized Official

Name: MR. GARY CERETTO
Title or Position: PHARMACIST OWNER
Credential: RPH
Phone: 618-288-7474