1205830999 NPI number — ORANGE BEACH FAMILY PHARMACY

Table of content: MR. JEFFREY BENNETT LAT, ATC (NPI 1043581754)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205830999 NPI number — ORANGE BEACH FAMILY PHARMACY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ORANGE BEACH FAMILY PHARMACY
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:
FAMILY PHARMACY OF ORANGE BEACH
Provider Other Organization Name Type Code:
5
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:
1205830999
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/04/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
25299 A CANAL ROAD #6
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORANGE BEACH
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36561
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
251-981-2255
Provider Business Mailing Address Fax Number:
251-981-2282

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25299 A CANAL ROAD #6
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORANGE BEACH
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36561
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
251-981-2255
Provider Business Practice Location Address Fax Number:
251-981-2282
Provider Enumeration Date:
06/09/2005

Additional Information

Authorized Official

Authorized Official Last Name:
CARRANZA
Authorized Official First Name:
PATTISUE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
251-981-2255

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  110764 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X , with the licence number: 110764 , 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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