Healthcare Provider Details

I. General information

NPI: 1770839771
Provider Name (Legal Business Name): TRIAD RX, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2012
Last Update Date: 07/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26258 POLLARD RD
DAPHNE AL
36526-4250
US

IV. Provider business mailing address

PO BOX 1530
DAPHNE AL
36526-1530
US

V. Phone/Fax

Practice location:
  • Phone: 251-380-7630
  • Fax: 251-380-7631
Mailing address:
  • Phone: 251-380-7630
  • Fax: 251-380-7631

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number113869
License Number StateAL

VIII. Authorized Official

Name: ROBERT ROBERTS
Title or Position: PHARMACIST IN CHARGE
Credential:
Phone: 251-380-7630