=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336647007
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARROLL PHARMACY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/29/2018
-----------------------------------------------------
Last Update Date | 01/29/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 835 PICKWICK ST
-----------------------------------------------------
City | SAVANNAH
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38372-3006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 731-925-5551
-----------------------------------------------------
Fax | 731-925-5724
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 835 PICKWICK ST
-----------------------------------------------------
City | SAVANNAH
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38372-3006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 731-925-5551
-----------------------------------------------------
Fax | 731-925-5724
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DAVID ALLEN CARROLL
-----------------------------------------------------
Credential | PHARMD
-----------------------------------------------------
Telephone | 731-925-5551
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------