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General NPI Number Information
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NPI Number | 1194247080
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Entity Type | Organization
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Legal Business Name | 11 SOUTH MEDICAL PHARMACY, LLC
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Dates
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Enumeration Date | 07/12/2017
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Last Update Date | 07/28/2017
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Provider Practice Location Address
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Address Line | 1000 ELEVEN SOUTH STE 2B
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City | COLUMBIA
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State | IL
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Zip | 62236
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Country | US
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Telephone | 618-281-3500
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Fax |
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Provider Business Mailing Address
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Address Line | 1000 ELEVEN S STE 2B
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City | COLUMBIA
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State | IL
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Zip | 62236-1079
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Country | US
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Telephone | 618-281-3500
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Fax |
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Authorized Official
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Title or Position | PHARMACY MANAGER
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Name | KELSIE LIDER
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Credential | PHARMD
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Telephone | 618-281-3500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number | 054020346
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License Number State | IL
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