MEDICARE: MARBLE CITY PHARMACY INC

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	332B00000X	Durable Medical Equipment & Medical Supplies	112273	AL
2	183500000X	Pharmacist	112273	AL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0131730	OTHER	AL	NABP
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1417954488
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARBLE CITY PHARMACY INC

Provider Business Mailing Address
First Line	:	264 W FORT WILLIAMS ST
Second Line	:
City	:	SYLACAUGA
State	:	AL
Zip	:	35150-2432
Country	:	US
Telephone Number	:	256-245-4446
Fax Number	:	256-245-4484

Provider Business Practice Location Address
First Line	:	264 W FORT WILLIAMS ST
Second Line	:
City	:	SYLACAUGA
State	:	AL
Zip	:	35150-2432
Country	:	US
Telephone Number	:	256-245-4446
Fax Number	:	256-245-4484

Authorized Official
Title or Position	:	OWNER
Name	:	MR. JACOB MILES JOHNSON
Credential	:	PHARMD
Telephone Number	:	256-245-4446

Provider Enumeration Date	:	07/05/2005
Last Update Date	:	12/29/2010

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