1982929782 NPI number — LEESBURG PHARMACY, INC. DBA LOOKOUT MOUNTAIN PHARMACY

Table of content: (NPI 1982929782)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982929782 NPI number — LEESBURG PHARMACY, INC. DBA LOOKOUT MOUNTAIN PHARMACY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LEESBURG PHARMACY, INC. DBA LOOKOUT MOUNTAIN PHARMACY
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:
LOOKOUT MOUNTAIN 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:
1982929782
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 358
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEESBURG
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35983-0358
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-526-6337
Provider Business Mailing Address Fax Number:
256-526-6342

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1955 SAND ROCK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANDROCK
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35983-4327
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-523-5665
Provider Business Practice Location Address Fax Number:
256-523-5669
Provider Enumeration Date:
04/05/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ST.CLAIR
Authorized Official First Name:
CHRIS
Authorized Official Middle Name:
N
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
256-526-6337

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  113381 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 113381 . This is a "STATE OF ALABAMA BOARD OF PHARMACY LICENSE #" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".