Healthcare Provider Details

I. General information

NPI: 1679811160
Provider Name (Legal Business Name): COLLINSVILLE EXPRESS DRUGS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2013
Last Update Date: 03/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

588 S VALLEY AVE
COLLINSVILLE AL
35961-3535
US

IV. Provider business mailing address

PO BOX 4498
COLLINSVILLE AL
35961
US

V. Phone/Fax

Practice location:
  • Phone: 256-524-2981
  • Fax: 256-524-2987
Mailing address:
  • Phone: 256-524-2981
  • Fax: 256-524-2987

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number112980
License Number StateAL

VIII. Authorized Official

Name: BRANDON BOSWELL
Title or Position: OWNER/PIC
Credential:
Phone: 256-524-2981