1578991584 NPI number — BRYARS-WARREN DRUG CO, LLC

Table of content: (NPI 1578991584)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578991584 NPI number — BRYARS-WARREN DRUG CO, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRYARS-WARREN DRUG CO, 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:
BRYARS-WARREN DRUG CO
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:
1578991584
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/09/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
112 N MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ENTERPRISE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36330-2537
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-347-2506
Provider Business Mailing Address Fax Number:
334-393-8155

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
112 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ENTERPRISE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36330-2537
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-347-2506
Provider Business Practice Location Address Fax Number:
334-393-8155
Provider Enumeration Date:
10/30/2013

Additional Information

Authorized Official

Authorized Official Last Name:
WILLETTE
Authorized Official First Name:
JEREMY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/PIC
Authorized Official Telephone Number:
334-347-2506

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  101880 , 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: 2142646 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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