Healthcare Provider Details

I. General information

NPI: 1942011663
Provider Name (Legal Business Name): FORT PAYNE PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2025
Last Update Date: 01/14/2025
Certification Date: 01/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1614A GLENN BLVD SW
FORT PAYNE AL
35968-3522
US

IV. Provider business mailing address

1614A GLENN BLVD SW
FORT PAYNE AL
35968-3522
US

V. Phone/Fax

Practice location:
  • Phone: 256-845-3402
  • Fax: 256-845-3289
Mailing address:
  • Phone: 256-845-3402
  • Fax: 256-845-3289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: LEATRICIA LYNN BONNER
Title or Position: OWNER
Credential:
Phone: 256-845-3402