Provider Demographics
NPI:1326154238
Name:ALTON MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:ALTON MEMORIAL HOSPITAL
Other - Org Name:FAMILY CARE PHARMACY AT ALTON MEMORIAL HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:BRAASCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-463-7301
Mailing Address - Street 1:1 MEMORIAL DR
Mailing Address - Street 2:ROOM G247
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-6722
Mailing Address - Country:US
Mailing Address - Phone:618-463-7865
Mailing Address - Fax:618-463-7884
Practice Address - Street 1:1 MEMORIAL DR
Practice Address - Street 2:ROOM G247
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-6722
Practice Address - Country:US
Practice Address - Phone:618-463-7865
Practice Address - Fax:618-463-7884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IL0540116443336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2022352OtherPK
IL=========006Medicaid
IL=========006Medicaid