MEDICARE: PEACOCK 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	3336M0002X	Mail Order Pharmacy
2	333600000X	Pharmacy
3	3336C0003X	Community/Retail Pharmacy	10993	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4229680	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1942528278
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEACOCK PHARMACY LLC

Provider Business Mailing Address
First Line	:	1201 HIGHWAY 37 19E
Second Line	:	SUITE 3
City	:	ELIZABETHTON
State	:	TN
Zip	:	37643-4678
Country	:	US
Telephone Number	:	423-542-2195
Fax Number	:

Provider Business Practice Location Address
First Line	:	550 S CHURCH ST STE 9
Second Line	:
City	:	SPARTANBURG
State	:	SC
Zip	:	29306-3306
Country	:	US
Telephone Number	:	864-596-4501
Fax Number	:	864-596-4503

Authorized Official
Title or Position	:	PHARMACIST
Name	:	DIANDRA BROOKS
Credential	:
Telephone Number	:	864-596-4501

Provider Enumeration Date	:	05/11/2010
Last Update Date	:	09/01/2010

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Directions to “PEACOCK PHARMACY LLC ” Practice Location

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