Healthcare Provider Details

I. General information

NPI: 1841620960
Provider Name (Legal Business Name): GROCERIES OF SOUTHERN ILLINOIS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2013
Last Update Date: 10/15/2021
Certification Date: 09/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 SPOTSYLVANIA ST
NEW ATHENS IL
62264-1569
US

IV. Provider business mailing address

10 SOUTHGATE CTR
FREEBURG IL
62243-1541
US

V. Phone/Fax

Practice location:
  • Phone: 618-566-6843
  • Fax: 618-475-9219
Mailing address:
  • Phone: 618-539-5577
  • Fax: 618-539-3089

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number054018344
License Number StateIL

VIII. Authorized Official

Name: DR. BRYAN SCHNEIDER
Title or Position: DIRECTOR OF PHARMACY
Credential: PHARMD
Phone: 618-539-5577