Healthcare Provider Details

I. General information

NPI: 1740474204
Provider Name (Legal Business Name): FAYETTE PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2007
Last Update Date: 02/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13532 HIGHWAY 96
MILLPORT AL
35576-2522
US

IV. Provider business mailing address

PO BOX 408
MILLPORT AL
35576-0408
US

V. Phone/Fax

Practice location:
  • Phone: 205-662-3817
  • Fax: 205-662-4757
Mailing address:
  • Phone: 205-662-3817
  • Fax: 205-662-4757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number105645
License Number StateAL

VIII. Authorized Official

Name: SUMMER WILSON
Title or Position: OWNER/PHARMACIST
Credential:
Phone: 205-712-1685