Provider Demographics
NPI:1710080874
Name:FOX FAMILY PHARMACY INC
Entity Type:Organization
Organization Name:FOX FAMILY PHARMACY INC
Other - Org Name:FOX FAMILY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:FOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-576-2619
Mailing Address - Street 1:PO BOX 190
Mailing Address - Street 2:
Mailing Address - City:HARDIN
Mailing Address - State:IL
Mailing Address - Zip Code:62047-0190
Mailing Address - Country:US
Mailing Address - Phone:618-576-2619
Mailing Address - Fax:618-576-2275
Practice Address - Street 1:110 N COUNTY RD.
Practice Address - Street 2:
Practice Address - City:HARDIN
Practice Address - State:IL
Practice Address - Zip Code:62047
Practice Address - Country:US
Practice Address - Phone:618-576-2619
Practice Address - Fax:618-576-2275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IL0540148133336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2023132OtherPK
IL=========001Medicaid