Healthcare Provider Details

I. General information

NPI: 1114064441
Provider Name (Legal Business Name): ESCAMBIA DRUG STORE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 S MAIN STREET
ATMORE AL
36502-2446
US

IV. Provider business mailing address

108 S MAIN STREET
ATMORE AL
36502-2446
US

V. Phone/Fax

Practice location:
  • Phone: 251-368-3191
  • Fax: 251-368-1916
Mailing address:
  • Phone: 251-368-3191
  • Fax: 251-368-1916

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number103720
License Number StateAL

VIII. Authorized Official

Name: MR. DAVID DEWAYNE BARNETT
Title or Position: REG PHARMACIST INS TRES OF CORPERAT
Credential: REG PHARMACIST
Phone: 251-368-3191