Provider Demographics
NPI:1770589210
Name:FAMILY PHARMACY OF COLLINSVILLE, INC
Entity type:Organization
Organization Name:FAMILY PHARMACY OF COLLINSVILLE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF PHARMACIST/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:L
Authorized Official - Last Name:WEISS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:618-345-2880
Mailing Address - Street 1:228 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62234-3016
Mailing Address - Country:US
Mailing Address - Phone:618-345-2880
Mailing Address - Fax:618-345-0899
Practice Address - Street 1:228 W MAIN ST
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62234-3016
Practice Address - Country:US
Practice Address - Phone:618-345-2880
Practice Address - Fax:618-345-0899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========001Medicaid