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General NPI Number Information
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NPI Number | 1063767424
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Entity Type | Organization
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Legal Business Name | SOUTHERN ILLINOIS HEALTHCARE FOUNDATION, INC.
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Dates
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Enumeration Date | 07/20/2012
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Last Update Date | 10/07/2025
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Provider Practice Location Address
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Address Line | 1200 N EAST ST
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City | OLNEY
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State | IL
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Zip | 62450-2432
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Country | US
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Telephone | 618-395-8561
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Fax |
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Provider Business Mailing Address
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Address Line | 2041 GOOSE LAKE RD
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City | SAUGET
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State | IL
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Zip | 62206-2822
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Country | US
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Telephone | 618-332-0953
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Fax | 618-332-2487
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Authorized Official
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Title or Position | CEO
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Name | MR. LARRY MCCULLEY
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Credential |
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Telephone | 618-332-0694
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 054017914
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License Number State | IL
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