=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790162311
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CALLAWAY GULF COAST PHARMACY CO
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2015
-----------------------------------------------------
Last Update Date | 02/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 420 N TYNDALL PKWY
-----------------------------------------------------
City | PANAMA CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32404-6125
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-615-2000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 420 N TYNDALL PKWY
-----------------------------------------------------
City | PANAMA CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32404-6125
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-615-2000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | ADEL EBRAHIM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 850-319-3238
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PH29076
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------