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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