Healthcare Provider Details

I. General information

NPI: 1154461200
Provider Name (Legal Business Name): SAND DRUG INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1206 7TH ST SE
DECATUR AL
35601-3338
US

IV. Provider business mailing address

1206 7TH ST SE
DECATUR AL
35601-3338
US

V. Phone/Fax

Practice location:
  • Phone: 256-353-5011
  • Fax: 256-355-5152
Mailing address:
  • Phone: 256-353-5011
  • Fax: 256-355-5152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number107541
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number107541
License Number StateAL

VIII. Authorized Official

Name: BLAKE LEE GOWEN
Title or Position: OWNER/RPH IN CHARGE
Credential:
Phone: 256-353-5011