Provider Demographics
NPI:1225049729
Name:MORTON-WUEBBELS PHARMACY INC
Entity Type:Organization
Organization Name:MORTON-WUEBBELS PHARMACY INC
Other - Org Name:MEDICINE SHOPPE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LICENSEE
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MORTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-533-5411
Mailing Address - Street 1:817 E MCCORD
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:817 E MCCORD
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801
Practice Address - Country:US
Practice Address - Phone:618-533-5411
Practice Address - Fax:618-533-4153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IL0540157433336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1471161OtherOTHER ID NUMBER-COMMERCIAL NUMBER
1471161OtherOTHER ID NUMBER-COMMERCIAL NUMBER
ILBM9582986OtherDEA #
ILP00637429Medicare PIN
IL=========001Medicaid
IL5625230001Medicare NSC