Provider Demographics
NPI:1811543648
Name:MT VERNON COMMUNITY PHARMACY INC
Entity Type:Organization
Organization Name:MT VERNON COMMUNITY PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:ADAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-242-8776
Mailing Address - Street 1:2339 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-2925
Mailing Address - Country:US
Mailing Address - Phone:618-242-8776
Mailing Address - Fax:618-244-9475
Practice Address - Street 1:2339 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-2925
Practice Address - Country:US
Practice Address - Phone:618-242-8776
Practice Address - Fax:618-244-9475
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MT VERNON COMMUNITY PHARMACY INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-08-16
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy