Basic Information
| Provider Information | |||||||||
| NPI: | 1710992300 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE EAST ALABAMA HEALTH CARE AUTHORITY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | EAMC HOME CARE PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 665 OPELIKA RD | ||||||||
| Address2: | |||||||||
| City: | AUBURN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 368304013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3348217843 | ||||||||
| FaxNumber: | 3348218894 | ||||||||
| Practice Location | |||||||||
| Address1: | 665 OPELIKA RD | ||||||||
| Address2: | |||||||||
| City: | AUBURN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 368304013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3348217843 | ||||||||
| FaxNumber: | 3348218894 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2006 | ||||||||
| LastUpdateDate: | 12/30/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WOOD | ||||||||
| AuthorizedOfficialFirstName: | CRYSTAL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PHARMACIST | ||||||||
| AuthorizedOfficialTelephone: | 3348217843 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336S0011X | N | Suppliers | Pharmacy | Specialty Pharmacy | 333600000X | N | Suppliers | Pharmacy | 3336M0002X | 111272 | AL | Y | Suppliers | Pharmacy | Mail Order Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 0128579 | 01 | NCPDP PROVIDER IDENTIFICATION NUMBER | OTHER | 100010006 | 05 | AL | MEDICAID |