=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083972202
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HACKLEBURG PHARMACY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/25/2012
-----------------------------------------------------
Last Update Date | 08/09/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 34863 US HIGHWAY 43
-----------------------------------------------------
City | HACKLEBURG
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35564-4281
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-935-3392
-----------------------------------------------------
Fax | 205-935-3393
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 167
-----------------------------------------------------
City | HACKLEBURG
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35564-0167
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-935-3392
-----------------------------------------------------
Fax | 205-935-3393
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST/OWNER
-----------------------------------------------------
Name | VINCENT HUGHES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 205-935-3392
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 113891
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------