Provider Demographics
NPI:1437147246
Name:BYRD-WATSON SOUTH 9TH DRUG CO
Entity Type:Organization
Organization Name:BYRD-WATSON SOUTH 9TH DRUG CO
Other - Org Name:BYRD-WATSON MEDICAL DOWNTOWN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICER OF THE CORPORATION
Authorized Official - Prefix:
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:
Authorized Official - Last Name:BREEZE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-244-5400
Mailing Address - Street 1:PO BOX 1179
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-0024
Mailing Address - Country:US
Mailing Address - Phone:618-242-2800
Mailing Address - Fax:618-242-6775
Practice Address - Street 1:1200 MAIN ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-3821
Practice Address - Country:US
Practice Address - Phone:618-242-2800
Practice Address - Fax:618-244-4816
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-06
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 332BX2000X
ILBB2446690333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL140146OtherHEALTH ALLIANCE
IL177625OtherHEALTHLINK
IL4132044OtherBCBS OF IL
IL=========001Medicaid
IL=========001Medicaid