1356385983 NPI number — SYLACAUGA HEALTH CARE AUTHORITY INC

Table of content: (NPI 1356385983)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356385983 NPI number — SYLACAUGA HEALTH CARE AUTHORITY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SYLACAUGA HEALTH CARE AUTHORITY INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
COOSA VALLEY MEDICAL CENTER PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356385983
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/21/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
315 W HICKORY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SYLACAUGA
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35150-2913
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-401-4065
Provider Business Mailing Address Fax Number:
256-401-4099

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
315 W HICKORY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SYLACAUGA
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35150-2913
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-401-4065
Provider Business Practice Location Address Fax Number:
256-401-4099
Provider Enumeration Date:
06/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CRANE
Authorized Official First Name:
GREGORY
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF PHARMACY
Authorized Official Telephone Number:
256-401-4066

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336I0012X , with the licence number: 130008 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336L0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336M0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1989675 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 100010002 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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