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General NPI Number Information
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NPI Number | 1942528278
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Entity Type | Organization
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Legal Business Name | PEACOCK PHARMACY LLC
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Dates
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Enumeration Date | 05/11/2010
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Last Update Date | 09/01/2010
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Provider Practice Location Address
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Address Line | 550 S CHURCH ST STE 9
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City | SPARTANBURG
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State | SC
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Zip | 29306-3306
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Country | US
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Telephone | 864-596-4501
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Fax | 864-596-4503
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Provider Business Mailing Address
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Address Line | 1201 HIGHWAY 37 19E SUITE 3
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City | ELIZABETHTON
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State | TN
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Zip | 37643-4678
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Country | US
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Telephone | 423-542-2195
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Fax |
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Authorized Official
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Title or Position | PHARMACIST
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Name | DIANDRA BROOKS
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Credential |
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Telephone | 864-596-4501
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336M0002X
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Taxonomy Name | Mail Order Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 10993
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License Number State | SC
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