1932140712 NPI number — THE PHARMACY BOOTHE

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 1932140712 NPI number — THE PHARMACY BOOTHE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE PHARMACY BOOTHE
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:
1932140712
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3825 SULLIVAN ST
Provider Second Line Business Mailing Address:
SUITE 2
Provider Business Mailing Address City Name:
MADISON
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35758-1740
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-461-6376
Provider Business Mailing Address Fax Number:
256-461-6334

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3825 SULLIVAN ST
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
MADISON
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35758-1740
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-461-6376
Provider Business Practice Location Address Fax Number:
256-461-6334
Provider Enumeration Date:
06/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BOOTHE
Authorized Official First Name:
JEANNA
Authorized Official Middle Name:
SEWELL
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
256-461-6376

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  112348 , 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: 112348 . This is a "STATE LICENSE" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 515-19983 . This is a "BCBS DME PROVIDER" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 0132009 . This is a "NCPDP" identifier . This identifiers is of the category "OTHER".




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