Provider Demographics
NPI:1558433243
Name:K&S PHARMACIES OF SOUTHERN ILLINOIS LTD
Entity Type:Organization
Organization Name:K&S PHARMACIES OF SOUTHERN ILLINOIS LTD
Other - Org Name:MOODY HEALTH MART PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:DR
Authorized Official - First Name:SEAMUS
Authorized Official - Middle Name:NEAL
Authorized Official - Last Name:KLOOS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:618-443-2715
Mailing Address - Street 1:109 E BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:IL
Mailing Address - Zip Code:62286-1678
Mailing Address - Country:US
Mailing Address - Phone:618-443-2715
Mailing Address - Fax:618-443-6218
Practice Address - Street 1:109 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:IL
Practice Address - Zip Code:62286-1678
Practice Address - Country:US
Practice Address - Phone:618-443-2715
Practice Address - Fax:618-443-6218
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IL054-0153963336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1278769Medicaid
2016628OtherPK
LA1278769Medicaid
2016628OtherPK