Organization
MALLEX CORPORATION
Active
Other names
The Medicine Shoppe Pharmacy
Organization subpart
No
Provider details
NPI number
Authorized official
ETHAN VANDERSAND (PRESIDENT)
(618) 498-6461
Entity
Organization
Contact information
Practice address
400A W CARPENTER ST, JERSEYVILLE, IL 62052-2522
(618) 498-6461
(618) 639-9450
Mailing address
400A W CARPENTER ST, JERSEYVILLE, IL 62052-2522
(618) 498-6461
(618) 639-9450
Taxonomy
Speciality
Code
Description
License number
State
3336C0003X
Community/Retail Pharmacy
Primary
054.018000
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2137095
PK
—
Enumeration date
07/17/2012
Last updated
07/05/2016
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