MEDICARE: FRISCO CITY PHARMACY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy	113345	AL

General Provider Information

NPI Number	:	1124359286
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FRISCO CITY PHARMACY, LLC

Provider Business Mailing Address
First Line	:	3749 BOWDEN ST
Second Line	:
City	:	FRISCO CITY
State	:	AL
Zip	:	36445-3655
Country	:	US
Telephone Number	:	251-267-2111
Fax Number	:	251-267-2117

Provider Business Practice Location Address
First Line	:	3749 BOWDEN ST
Second Line	:
City	:	FRISCO CITY
State	:	AL
Zip	:	36445-3655
Country	:	US
Telephone Number	:	251-267-2111
Fax Number	:	251-267-2117

Authorized Official
Title or Position	:	OWNER
Name	:	MR. DESAK HICKS
Credential	:
Telephone Number	:	251-267-2111

Provider Enumeration Date	:	01/28/2010
Last Update Date	:	01/28/2010

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