MEDICARE: FAMILY PHARMACY OF COLLINSVILLE, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy		IL

General Provider Information

NPI Number	:	1770589210
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY PHARMACY OF COLLINSVILLE, INC

Provider Business Mailing Address
First Line	:	228 W MAIN ST
Second Line	:
City	:	COLLINSVILLE
State	:	IL
Zip	:	62234-3016
Country	:	US
Telephone Number	:	618-345-2880
Fax Number	:	618-345-0899

Provider Business Practice Location Address
First Line	:	228 W MAIN ST
Second Line	:
City	:	COLLINSVILLE
State	:	IL
Zip	:	62234-3016
Country	:	US
Telephone Number	:	618-345-2880
Fax Number	:	618-345-0899

Authorized Official
Title or Position	:	CHIEF PHARMACIST/PRESIDENT
Name	:	JUDITH L WEISS
Credential	:	RPH
Telephone Number	:	618-345-2880

Provider Enumeration Date	:	06/21/2005
Last Update Date	:	08/22/2020

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