1528512357 NPI number — SHELBY PHARMACY LLC

Table of content: (NPI 1528512357)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528512357 NPI number — SHELBY PHARMACY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHELBY PHARMACY 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:
EASLEY HEALTHMART 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:
1528512357
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/12/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
157 ARMISTEAD LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EASLEY
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29642-8636
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-503-5535
Provider Business Mailing Address Fax Number:
864-712-9279

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
401 HILLCREST DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EASLEY
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29640-1221
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-642-4879
Provider Business Practice Location Address Fax Number:
864-712-9279
Provider Enumeration Date:
08/10/2016

Additional Information

Authorized Official

Authorized Official Last Name:
SHELBY
Authorized Official First Name:
JERRY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER,PIC, AO
Authorized Official Telephone Number:
256-503-5535

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 16737 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 2162483 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 716737 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com