=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700089588
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STACEYS DRUG STORE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/07/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 109 COURTHOUSE SQ
-----------------------------------------------------
City | BAY MINETTE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36507-4813
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 251-937-5539
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 109 COURTHOUSE SQ
-----------------------------------------------------
City | BAY MINETTE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36507-4813
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 251-937-5539
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | LARRY K MOSLEY
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 251-937-5539
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 7186
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------