Healthcare Provider Details

I. General information

NPI: 1245344456
Provider Name (Legal Business Name): MEDI-AGE PHARMACEUTICALS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 03/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1433 3RD ST SW
ATTALLA AL
35954-1132
US

IV. Provider business mailing address

1433 3RD ST SW P.O. BOX 490
ATTALLA AL
35954-1132
US

V. Phone/Fax

Practice location:
  • Phone: 256-538-5850
  • Fax: 256-538-1860
Mailing address:
  • Phone: 256-538-5850
  • Fax: 256-538-1860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number108453
License Number StateAL

VIII. Authorized Official

Name: MR. RICKY A BEARDEN
Title or Position: PRESIDENT/PHARMACIST
Credential: R. PH.
Phone: 256-538-5850