Provider Demographics
NPI:1114243045
Name:SMITH, CHARLES THOMAS II (RPH)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:THOMAS
Last Name:SMITH
Suffix:II
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23355 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:FLORALA
Mailing Address - State:AL
Mailing Address - Zip Code:36442-3818
Mailing Address - Country:US
Mailing Address - Phone:334-858-3291
Mailing Address - Fax:334-858-5254
Practice Address - Street 1:23355 5TH AVE
Practice Address - Street 2:
Practice Address - City:FLORALA
Practice Address - State:AL
Practice Address - Zip Code:36442-3818
Practice Address - Country:US
Practice Address - Phone:334-858-3291
Practice Address - Fax:334-858-5254
Is Sole Proprietor?:No
Enumeration Date:2010-04-16
Last Update Date:2010-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL9068183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL100001169Medicaid
FL100513800Medicaid
AL100001169Medicaid