Basic Information
| Provider Information | |||||||||
| NPI: | 1588126809 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COOSA VALLEY APOTHECARY LL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 315 W HICKORY ST STE 150 | ||||||||
| Address2: | |||||||||
| City: | SYLACAUGA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 351502913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2564014534 | ||||||||
| FaxNumber: | 2564014603 | ||||||||
| Practice Location | |||||||||
| Address1: | 315 W HICKORY ST STE 150 | ||||||||
| Address2: | |||||||||
| City: | SYLACAUGA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 351502913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2564014534 | ||||||||
| FaxNumber: | 2564014603 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2019 | ||||||||
| LastUpdateDate: | 04/08/2019 | ||||||||
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| AuthorizedOfficialLastName: | THACKER | ||||||||
| AuthorizedOfficialFirstName: | ROLAND | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2564014534 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
No ID Information.