Healthcare Provider Details

I. General information

NPI: 1831104462
Provider Name (Legal Business Name): PCM PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 07/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1621 HIGHWAY 72
KILLEN AL
35645-9142
US

IV. Provider business mailing address

PO BOX 99
KILLEN AL
35645-0099
US

V. Phone/Fax

Practice location:
  • Phone: 256-757-1956
  • Fax: 256-757-1936
Mailing address:
  • Phone: 256-757-1956
  • Fax: 256-757-1936

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number111538
License Number StateAL

VIII. Authorized Official

Name: WILLIAM WOOD
Title or Position: MGR MEMBER
Credential: RPH
Phone: 256-757-1956