1053670687 NPI number — BERRY DISCOUNT APOTHECARY

Table of content: BENJAMIN CHARLES MISCAVAGE PT (NPI 1740097740)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053670687 NPI number — BERRY DISCOUNT APOTHECARY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BERRY DISCOUNT APOTHECARY
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:
1053670687
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/01/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
31 DEPOT ST
Provider Second Line Business Mailing Address:
P.O. BOX 424
Provider Business Mailing Address City Name:
BERRY
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35546-2086
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-689-4777
Provider Business Mailing Address Fax Number:
205-689-4778

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
31 DEPOT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BERRY
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35546-2086
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-689-4777
Provider Business Practice Location Address Fax Number:
205-689-4778
Provider Enumeration Date:
05/16/2012

Additional Information

Authorized Official

Authorized Official Last Name:
BOLLING
Authorized Official First Name:
GEORGE
Authorized Official Middle Name:
R
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
205-689-4777

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , 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)





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