Healthcare Provider Details

I. General information

NPI: 1790006617
Provider Name (Legal Business Name): PBP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2010
Last Update Date: 10/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12831 6TH ST
LILLIAN AL
36549-4166
US

IV. Provider business mailing address

PO BOX 59
LILLIAN AL
36549-0059
US

V. Phone/Fax

Practice location:
  • Phone: 251-962-3777
  • Fax: 251-962-3779
Mailing address:
  • Phone: 251-962-3777
  • Fax: 251-962-3779

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number112196
License Number StateAL

VIII. Authorized Official

Name: MR. ROBERT STEPHEN LOVE
Title or Position: PRESIDENT
Credential: RPH
Phone: 251-962-3777