Healthcare Provider Details

I. General information

NPI: 1063767424
Provider Name (Legal Business Name): SOUTHERN ILLINOIS HEALTHCARE FOUNDATION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2012
Last Update Date: 10/07/2025
Certification Date: 10/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N EAST ST
OLNEY IL
62450-2432
US

IV. Provider business mailing address

2041 GOOSE LAKE RD
SAUGET IL
62206-2822
US

V. Phone/Fax

Practice location:
  • Phone: 618-395-8561
  • Fax:
Mailing address:
  • Phone: 618-332-0953
  • Fax: 618-332-2487

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number054017914
License Number StateIL

VIII. Authorized Official

Name: MR. LARRY MCCULLEY
Title or Position: CEO
Credential:
Phone: 618-332-0694