Healthcare Provider Details

I. General information

NPI: 1649264722
Provider Name (Legal Business Name): K&S PHARMACIES OF SOUTHERN ILLINOIS LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2005
Last Update Date: 10/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

157 W BROADWAY ST
SPARTA IL
62286-1619
US

IV. Provider business mailing address

157 W BROADWAY ST
SPARTA IL
62286-1619
US

V. Phone/Fax

Practice location:
  • Phone: 618-443-2715
  • Fax: 618-443-6218
Mailing address:
  • Phone: 618-443-2715
  • Fax: 618-443-6218

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number054015396
License Number StateIL

VIII. Authorized Official

Name: DR. SEAMUS N KLOOS
Title or Position: CORP TREASURER/PHARMACIST IN CHARGE
Credential: PHARM.D.
Phone: 618-443-2715