=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194730705
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LINEVILLE CLINIC PHARMACY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/30/2006
-----------------------------------------------------
Last Update Date | 07/19/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3705 HIGHWAY 431 STE B
-----------------------------------------------------
City | ROANOKE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36274-1430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-863-6337
-----------------------------------------------------
Fax | 334-863-6339
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 248
-----------------------------------------------------
City | ROANOKE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36274-0248
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MARK LOWRY
-----------------------------------------------------
Credential | PHRM
-----------------------------------------------------
Telephone | 334-863-6337
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0002X
-----------------------------------------------------
Taxonomy Name | Clinic Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 114138
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------