Provider Demographics
NPI:1306241146
Name:MDM HEALTHCARE INC
Entity type:Organization
Organization Name:MDM HEALTHCARE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:EPPS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:618-632-8309
Mailing Address - Street 1:122 W STATE STREET
Mailing Address - Street 2:
Mailing Address - City:OFALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269
Mailing Address - Country:US
Mailing Address - Phone:618-632-8309
Mailing Address - Fax:
Practice Address - Street 1:122 W STATE STREET
Practice Address - Street 2:
Practice Address - City:OFALLON
Practice Address - State:IL
Practice Address - Zip Code:62269
Practice Address - Country:US
Practice Address - Phone:618-632-8309
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-22
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL054018756183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty