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General NPI Number Information
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NPI Number | 1245344456
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Entity Type | Organization
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Legal Business Name | MEDI-AGE PHARMACEUTICALS INC
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Dates
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Enumeration Date | 08/18/2006
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Last Update Date | 03/16/2012
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Provider Practice Location Address
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Address Line | 1433 3RD ST SW
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City | ATTALLA
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State | AL
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Zip | 35954-1132
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Country | US
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Telephone | 256-538-5850
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Fax | 256-538-1860
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Provider Business Mailing Address
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Address Line | 1433 3RD ST SW P.O. BOX 490
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City | ATTALLA
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State | AL
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Zip | 35954-1132
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Country | US
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Telephone | 256-538-5850
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Fax | 256-538-1860
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Authorized Official
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Title or Position | PRESIDENT/PHARMACIST
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Name | MR. RICKY A BEARDEN
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Credential | R. PH.
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Telephone | 256-538-5850
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 108453
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License Number State | AL
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