Healthcare Provider Details

I. General information

NPI: 1093809402
Provider Name (Legal Business Name): APOTHECARY SHOPPE OF WEST SALEM INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 06/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 S MAIN ST
WEST SALEM IL
62476-1202
US

IV. Provider business mailing address

PO BOX 68
WEST SALEM IL
62476-0068
US

V. Phone/Fax

Practice location:
  • Phone: 618-456-3716
  • Fax: 618-456-2029
Mailing address:
  • Phone: 618-456-3716
  • Fax: 618-456-2029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number054008438
License Number StateIL

VIII. Authorized Official

Name: KIMBERLEY GRIFFITH
Title or Position: PRES
Credential: RPH
Phone: 618-456-3716