{
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"EIN": null,
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"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "11 SOUTH MEDICAL PHARMACY, LLC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
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"OtherLastName": null,
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"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "1000 ELEVEN S STE 2B",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "COLUMBIA",
"MailingAddressStateName": "IL",
"MailingAddressPostalCode": "62236-1079",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "618-281-3500",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "1000 ELEVEN SOUTH",
"SecondLinePracticeLocationAddress": "STE 2B",
"PracticeLocationAddressCityName": "COLUMBIA",
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"PracticeLocationAddressPostalCode": "62236",
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"PracticeLocationAddressTelephoneNumber": "618-281-3500",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "07/12/2017",
"LastUpdateDate": "07/28/2017",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "LIDER",
"AuthorizedOfficialFirstName": "KELSIE",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "PHARMACY MANAGER",
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"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "PHARMD",
"AuthorizedOfficialTelephoneNumber": "618-281-3500",
"Taxonomies": {
"Taxonomy": {
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"TaxonomyName": "Pharmacy",
"LicenseNumber": "054020346",
"LicenseNumberStateCode": "IL",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}