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General NPI Number Information
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NPI Number | 1144339995
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Entity Type | Organization
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Legal Business Name | ATHENS CREEKSIDE DRUGS, LLC
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Dates
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Enumeration Date | 08/29/2006
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Last Update Date | 01/26/2011
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Provider Practice Location Address
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Address Line | 605 US HIGHWAY 31 S SUITE D
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City | ATHENS
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State | AL
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Zip | 35611-3645
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Country | US
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Telephone | 256-232-8274
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Fax | 256-232-2029
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Provider Business Mailing Address
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Address Line | 605 US HIGHWAY 31 S SUITE D
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City | ATHENS
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State | AL
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Zip | 35611-3645
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Country | US
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Telephone | 256-232-8274
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Fax | 256-232-2029
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Authorized Official
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Title or Position | OWNER/PHARMACIST
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Name | MR. MARK KENT JACKSON
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Credential |
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Telephone | 256-232-8274
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 111879
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License Number State | AL
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