Provider Demographics
NPI:1326082173
Name:MARYVILLE PHARMACY INC
Entity type:Organization
Organization Name:MARYVILLE PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:CERETTO
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:618-288-7474
Mailing Address - Street 1:2700 N CENTER ST
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-5624
Mailing Address - Country:US
Mailing Address - Phone:618-288-7474
Mailing Address - Fax:618-288-1860
Practice Address - Street 1:2700 N CENTER ST
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-5624
Practice Address - Country:US
Practice Address - Phone:618-288-7474
Practice Address - Fax:618-288-1860
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty