Provider Demographics
NPI:1982001996
Name:PRINCIPIA HEALTH & WELLNESS PHARMACY INC
Entity Type:Organization
Organization Name:PRINCIPIA HEALTH & WELLNESS PHARMACY INC
Other - Org Name:SHIELDS FAMILY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/PHARMACIST IN CHARGE
Authorized Official - Prefix:DR
Authorized Official - First Name:SETH
Authorized Official - Middle Name:K
Authorized Official - Last Name:ANATO
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:314-517-9035
Mailing Address - Street 1:1 PROFESSIONAL DR STE 170
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-5069
Mailing Address - Country:US
Mailing Address - Phone:618-463-0000
Mailing Address - Fax:618-463-0008
Practice Address - Street 1:1 PROFESSIONAL DR STE 170
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-5069
Practice Address - Country:US
Practice Address - Phone:618-463-0000
Practice Address - Fax:618-463-0008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0540188383336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2148900OtherPK