Healthcare Provider Details

I. General information

NPI: 1952612848
Provider Name (Legal Business Name): PEACOCK PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2010
Last Update Date: 07/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2099 E MAIN ST STE G
DUNCAN SC
29334-8886
US

IV. Provider business mailing address

1201 HWY 19E BYASS SUITE 3
ELIZABETHTON TN
37643
US

V. Phone/Fax

Practice location:
  • Phone: 864-486-8252
  • Fax:
Mailing address:
  • Phone: 423-547-3224
  • Fax: 800-419-1565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: ADAM WELLINGTON
Title or Position: PRESIDENT
Credential:
Phone: 423-547-3224