Provider Demographics
NPI:1720132566
Name:ALTON MENTAL HEALTH CENTER
Entity Type:Organization
Organization Name:ALTON MENTAL HEALTH CENTER
Other - Org Name:ILLINOIS DEPARTMENT OF HUMAN SERVICES
Other - Org Type:Other Name
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:GLENN
Authorized Official - Last Name:VARNUM
Authorized Official - Suffix:
Authorized Official - Credentials:BS RPH
Authorized Official - Phone:618-474-3408
Mailing Address - Street 1:4500 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-5051
Mailing Address - Country:US
Mailing Address - Phone:618-474-3408
Mailing Address - Fax:618-474-3959
Practice Address - Street 1:4500 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-5051
Practice Address - Country:US
Practice Address - Phone:618-474-3408
Practice Address - Fax:618-474-3959
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL059.007697283Q00000X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No283Q00000XHospitalsPsychiatric Hospital