Provider Demographics
NPI:1972525970
Name:ALTON MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:ALTON MEMORIAL HOSPITAL
Other - Org Name:HOME CARE PHARMACY LTC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:MUELLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-463-7425
Mailing Address - Street 1:1 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-6722
Mailing Address - Country:US
Mailing Address - Phone:618-463-7610
Mailing Address - Fax:618-463-7722
Practice Address - Street 1:1 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-6722
Practice Address - Country:US
Practice Address - Phone:618-463-7610
Practice Address - Fax:618-463-7722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0540171723336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1466843OtherNCPDP PROVIDER IDENTIFICATION NUMBER