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Organization
MT VERNON COMMUNITY PHARMACY INC
Active
Organization
MT VERNON COMMUNITY PHARMACY INC
Active
Other names
The Medicine Shoppe
Organization subpart
No
Provider details
NPI number
Authorized official
ERIC BLACK (OWNER)
(618) 242-8776
Entity
Organization
Contact information
Practice address
2339 BROADWAY ST, MOUNT VERNON, IL 62864-2925
(618) 242-8776
Mailing address
2339 BROADWAY ST, MOUNT VERNON, IL 62864-2925
(618) 242-8776
Taxonomy
Speciality
Code
Description
License number
State
3336C0003X
Community/Retail Pharmacy
Primary
054016737
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1447792
NCPDP PROVIDER IDENTIFICATION NUMBER
—
01
—
334555
HEALTHLINK
—
01
—
4132021
BLUE CROSS BLUE SHIELD
—
Enumeration date
02/24/2006
Last updated
11/01/2011
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