Healthcare Provider Details

I. General information

NPI: 1285728691
Provider Name (Legal Business Name): MLM PHARMACY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 N BROADWAY AVE
SALEM IL
62881-1511
US

IV. Provider business mailing address

215 N BROADWAY AVE
SALEM IL
62881-1511
US

V. Phone/Fax

Practice location:
  • Phone: 618-548-0070
  • Fax: 618-548-9846
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number054014788
License Number StateIL

VIII. Authorized Official

Name: MICHAEL MORTON
Title or Position: OWNER
Credential:
Phone: 618-548-0070