=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477087054
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HUNTSVILLE GI PHARMACY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/20/2017
-----------------------------------------------------
Last Update Date | 04/20/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 119 LONGWOOD DR SW SUITE 200A
-----------------------------------------------------
City | HUNTSVILLE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35801-4522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-572-0009
-----------------------------------------------------
Fax | 817-720-1039
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1620 W NORTHWEST HWY SUITE 100
-----------------------------------------------------
City | GRAPEVINE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76051-3177
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-572-0009
-----------------------------------------------------
Fax | 817-720-1039
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SENIOR OPERATIONS MANAGER
-----------------------------------------------------
Name | TAMMIE MISKIMINS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 817-572-0009
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336S0011X
-----------------------------------------------------
Taxonomy Name | Specialty 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 | 114706
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------