1316026164 NPI number — CLOVERLAND DRUG, INC

Table of content: (NPI 1316026164)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316026164 NPI number — CLOVERLAND DRUG, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLOVERLAND DRUG, INC
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:
FOUNTAIN CITY 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:
1316026164
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/21/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 240817
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONTGOMERY
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36124-0817
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-386-2742
Provider Business Mailing Address Fax Number:
334-386-2745

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
105 N MEMORIAL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRATTVILLE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36067-3332
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-365-3327
Provider Business Practice Location Address Fax Number:
334-365-3316
Provider Enumeration Date:
11/03/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SAALWAECHTER
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
334-322-2927

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  104085 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336M0002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 2143927 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 156110 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".