Healthcare Provider Details

I. General information

NPI: 1457429144
Provider Name (Legal Business Name): MCCONAGHY DRUG STORE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 11/24/2021
Certification Date: 11/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61 RIVER RD
MCINTOSH AL
36553
US

IV. Provider business mailing address

PO BOX 247
MC INTOSH AL
36553-0247
US

V. Phone/Fax

Practice location:
  • Phone: 251-944-8227
  • Fax: 251-944-8226
Mailing address:
  • Phone: 251-944-8227
  • Fax: 251-944-8226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number106354
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number106354
License Number StateAL
# 4
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. RANDY WARD DAVIDSON
Title or Position: DME DIRECTOR
Credential:
Phone: 251-944-8227