Healthcare Provider Details

I. General information

NPI: 1588062004
Provider Name (Legal Business Name): PARKS AVENUE DRUGS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2014
Last Update Date: 12/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 PARKS AVE STE F
SCOTTSBORO AL
35768-2437
US

IV. Provider business mailing address

410 PARKS AVE STE F
SCOTTSBORO AL
35768-2437
US

V. Phone/Fax

Practice location:
  • Phone: 256-999-0410
  • Fax: 256-999-0411
Mailing address:
  • Phone: 256-999-0410
  • Fax: 256-999-0411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number114439
License Number StateAL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2149300
Identifier TypeOTHER
Identifier State
Identifier IssuerPK

VIII. Authorized Official

Name: WILLIAM HANEY
Title or Position: SUPERVISOR PHARMACIST
Credential:
Phone: 256-999-0410