1417954488 NPI number — MARBLE CITY PHARMACY INC

Table of content: (NPI 1417954488)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417954488 NPI number — MARBLE CITY PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARBLE CITY PHARMACY 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:
Provider Other Organization Name Type Code:
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:
1417954488
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/29/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
264 W FORT WILLIAMS 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:
35150-2432
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-245-4446
Provider Business Mailing Address Fax Number:
256-245-4484

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
264 W FORT WILLIAMS 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:
35150-2432
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-245-4446
Provider Business Practice Location Address Fax Number:
256-245-4484
Provider Enumeration Date:
07/05/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
JACOB
Authorized Official Middle Name:
MILES
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
256-245-4446

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  112273 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332B00000X , with the licence number: 112273 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0131730 . This is a "NABP" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 100003479 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 009932695 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".