1427384577 NPI number — SHOALS FAMILY PHARMACY GROUP INC

Table of content: MICHAEL ARELLANO ATC, LAT (NPI 1508331307)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427384577 NPI number — SHOALS FAMILY PHARMACY GROUP INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHOALS FAMILY PHARMACY GROUP 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:
6
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:
1427384577
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/20/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
455 UNDERWOOD RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RUSSELLVILLE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35653-4111
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-332-5545
Provider Business Mailing Address Fax Number:
256-332-5582

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
318 JACKSON AVE S
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
RUSSELLVILLE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35653-2207
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-332-8550
Provider Business Practice Location Address Fax Number:
256-332-8081
Provider Enumeration Date:
10/26/2009

Additional Information

Authorized Official

Authorized Official Last Name:
LANE
Authorized Official First Name:
JEREMY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/PHARMACIST
Authorized Official Telephone Number:
256-810-3331

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  113306 , 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: 2122271 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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