Provider Demographics
NPI:1023363025
Name:MALLEX CORPORATION
Entity Type:Organization
Organization Name:MALLEX CORPORATION
Other - Org Name:THE MEDICINE SHOPPE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ETHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:VANDERSAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-498-6461
Mailing Address - Street 1:400A W CARPENTER ST
Mailing Address - Street 2:
Mailing Address - City:JERSEYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62052-2522
Mailing Address - Country:US
Mailing Address - Phone:618-498-6461
Mailing Address - Fax:618-639-9450
Practice Address - Street 1:400A W CARPENTER ST
Practice Address - Street 2:
Practice Address - City:JERSEYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62052-2522
Practice Address - Country:US
Practice Address - Phone:618-498-6461
Practice Address - Fax:618-639-9450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-17
Last Update Date:2016-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL054.0180003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2137095OtherPK