Healthcare Provider Details

I. General information

NPI: 1457716144
Provider Name (Legal Business Name): ROANE PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2015
Last Update Date: 03/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 JANE WAY LN STE 1
JACKSBORO TN
37757-2704
US

IV. Provider business mailing address

PO BOX 695
CODEN AL
36523-0695
US

V. Phone/Fax

Practice location:
  • Phone: 251-232-0590
  • Fax:
Mailing address:
  • Phone: 251-232-0590
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number5646
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: LYNN HUYNH
Title or Position: OWNER
Credential:
Phone: 251-232-0590