Provider Demographics
NPI:1528073178
Name:GROCERIES OF SOUTHERN ILLINOIS LLC
Entity type:Organization
Organization Name:GROCERIES OF SOUTHERN ILLINOIS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:VICTOR
Authorized Official - Last Name:SCHNEIDER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:618-207-3186
Mailing Address - Street 1:PO BOX 140
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:IL
Mailing Address - Zip Code:62236-0140
Mailing Address - Country:US
Mailing Address - Phone:618-539-5577
Mailing Address - Fax:618-539-3089
Practice Address - Street 1:10 SOUTHGATE CTR
Practice Address - Street 2:
Practice Address - City:FREEBURG
Practice Address - State:IL
Practice Address - Zip Code:62243-1541
Practice Address - Country:US
Practice Address - Phone:618-539-5577
Practice Address - Fax:618-539-3089
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IL0540095383336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2019782OtherPK
IL371239582001Medicaid