1154667970 NPI number — COPELAND PHARMACEUTICAL SERVICES LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154667970 NPI number — COPELAND PHARMACEUTICAL SERVICES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COPELAND PHARMACEUTICAL SERVICES LLC
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:
CITY PHARMACY OF RUSSELLVILLE
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:
1154667970
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/03/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
104 OLD CAPE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUSCUMBIA
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35674-5216
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-616-3311
Provider Business Mailing Address Fax Number:
256-389-2992

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14001 HIGHWAY 43
Provider Second Line Business Practice Location Address:
STE 13
Provider Business Practice Location Address City Name:
RUSSELLVILLE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35653-2848
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-331-1919
Provider Business Practice Location Address Fax Number:
256-331-1960
Provider Enumeration Date:
12/26/2012

Additional Information

Authorized Official

Authorized Official Last Name:
COPELAND
Authorized Official First Name:
GRANT
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
256-616-3311

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  114022 , 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: 144805 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2138439 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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