Healthcare Provider Details

I. General information

NPI: 1114191459
Provider Name (Legal Business Name): FAYETTE PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2008
Last Update Date: 07/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1128 2ND AVE NE
FAYETTE AL
35555-1739
US

IV. Provider business mailing address

1128 2ND AVE NE
FAYETTE AL
35555-1739
US

V. Phone/Fax

Practice location:
  • Phone: 205-932-5400
  • Fax: 205-932-5401
Mailing address:
  • Phone: 205-932-5400
  • Fax: 205-932-5401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number113087
License Number StateAL

VIII. Authorized Official

Name: SUMMER WILSON
Title or Position: PHRMD
Credential:
Phone: 205-712-1685