Provider Demographics
NPI:1861535460
Name:MILLSTADT PHARMACY
Entity type:Organization
Organization Name:MILLSTADT PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY TECH
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVINROY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-476-1701
Mailing Address - Street 1:120 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:MILLSTADT
Mailing Address - State:IL
Mailing Address - Zip Code:62260-1156
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:120 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MILLSTADT
Practice Address - State:IL
Practice Address - Zip Code:62260-1156
Practice Address - Country:US
Practice Address - Phone:618-476-1701
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid