1649619222 NPI number — CAREDIRECT RX OF JACKSON, 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 1649619222 NPI number — CAREDIRECT RX OF JACKSON, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CAREDIRECT RX OF JACKSON, 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:
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:
1649619222
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/18/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 531144
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BIRMINGHAM
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35253-1144
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-414-6681
Provider Business Mailing Address Fax Number:
205-930-0405

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
112 CELTIC DR STE 200A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MADISON
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35758-1800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-325-2148
Provider Business Practice Location Address Fax Number:
256-325-2168
Provider Enumeration Date:
06/18/2013

Additional Information

Authorized Official

Authorized Official Last Name:
MCCOLLISTER
Authorized Official First Name:
PORTER
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
205-414-6681

Provider Taxonomy Codes

  • Taxonomy code: 3336L0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336M0002X , with the licence number: 114123 , 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: 2140602 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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