MEDICARE: LORETTO DRUGS L L C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	3933	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2093982	OTHER		PK

General Provider Information

NPI Number	:	1043225675
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LORETTO DRUGS L L C

Provider Business Mailing Address
First Line	:	PO BOX 278
Second Line	:
City	:	LORETTO
State	:	TN
Zip	:	38469-0278
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	106 CHURCH ST
Second Line	:
City	:	LORETTO
State	:	TN
Zip	:	38469-2143
Country	:	US
Telephone Number	:	931-853-5910
Fax Number	:	931-853-5930

Authorized Official
Title or Position	:	PIC
Name	:	TIMOTHY WAYNE
Credential	:
Telephone Number	:	931-853-5920

Provider Enumeration Date	:	07/30/2006
Last Update Date	:	12/01/2016

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