Healthcare Provider Details

I. General information

NPI: 1184917429
Provider Name (Legal Business Name): GULF COAST PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2011
Last Update Date: 09/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 AZALEA RD
MOBILE AL
36609-1501
US

IV. Provider business mailing address

515 AZALEA RD
MOBILE AL
36609-1501
US

V. Phone/Fax

Practice location:
  • Phone: 251-342-5519
  • Fax:
Mailing address:
  • Phone: 251-342-5519
  • Fax:

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 Number113142
License Number StateAL
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code3336N0007X
TaxonomyNuclear Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DAVID BUSH
Title or Position: PHARMACIST
Credential:
Phone: 251-404-3343