Healthcare Provider Details

I. General information

NPI: 1528100245
Provider Name (Legal Business Name): JOHN M GENTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 07/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

87458 US HIGHWAY 278
SNEAD AL
35952-9638
US

IV. Provider business mailing address

PO BOX 510
SNEAD AL
35952-0510
US

V. Phone/Fax

Practice location:
  • Phone: 205-466-7990
  • Fax: 205-466-3603
Mailing address:
  • Phone: 205-466-7990
  • Fax: 205-466-3603

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 Number108965
License Number StateAL

VIII. Authorized Official

Name: JOHN GENTRY
Title or Position: OWNER/PIC/AO
Credential: RPH
Phone: 205-466-7990