Provider Demographics
NPI:1235525270
Name:SOUTHERN ILLINOIS HOSPITAL SERVICES
Entity Type:Organization
Organization Name:SOUTHERN ILLINOIS HOSPITAL SERVICES
Other - Org Name:MEMORIAL HOSPITAL OF CARBONDALE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TRISTA
Authorized Official - Middle Name:
Authorized Official - Last Name:GIACOMO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-549-0721
Mailing Address - Street 1:405 W JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-1462
Mailing Address - Country:US
Mailing Address - Phone:618-549-0721
Mailing Address - Fax:618-529-0475
Practice Address - Street 1:405 W JACKSON ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1462
Practice Address - Country:US
Practice Address - Phone:618-549-0721
Practice Address - Fax:618-529-0475
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-07
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0540170533336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2150884OtherPK