Healthcare Provider Details

I. General information

NPI: 1124159058
Provider Name (Legal Business Name): HOMETOWN PHARMACY OF MEDINA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 04/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 S MAIN ST
MEDINA TN
38355-9702
US

IV. Provider business mailing address

PO BOX 310
MEDINA TN
38355-0310
US

V. Phone/Fax

Practice location:
  • Phone: 731-783-0777
  • Fax: 731-783-3005
Mailing address:
  • Phone: 731-783-0777
  • Fax: 731-783-3005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
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 Number4079
License Number StateTN

VIII. Authorized Official

Name: DONNA ROBBINS
Title or Position: PHARMACIST AND OWNER
Credential: DPH
Phone: 731-783-0777