Provider Demographics
NPI:1912075151
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:PHARMACIST IN CHARGE
Authorized Official - Prefix:MRS
Authorized Official - First Name:MEGHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HEURING
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:618-539-3164
Mailing Address - Street 1:1375 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RED BUD
Mailing Address - State:IL
Mailing Address - Zip Code:62278-1352
Mailing Address - Country:US
Mailing Address - Phone:618-282-6658
Mailing Address - Fax:618-282-6488
Practice Address - Street 1:1375 S MAIN ST
Practice Address - Street 2:
Practice Address - City:RED BUD
Practice Address - State:IL
Practice Address - Zip Code:62278-1352
Practice Address - Country:US
Practice Address - Phone:618-282-6658
Practice Address - Fax:618-282-6488
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GROCERIES OF SOUTHERN ILLINOIS, LLC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-04
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IL0540185663336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL371074357001Medicaid
2023324OtherPK
2023324OtherPK