Provider Demographics
NPI:1124159058
Name:HOMETOWN PHARMACY OF MEDINA LLC
Entity type:Organization
Organization Name:HOMETOWN PHARMACY OF MEDINA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST AND OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBBINS
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:731-783-0777
Mailing Address - Street 1:PO BOX 310
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:TN
Mailing Address - Zip Code:38355-0310
Mailing Address - Country:US
Mailing Address - Phone:731-783-0777
Mailing Address - Fax:731-783-3005
Practice Address - Street 1:107 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:TN
Practice Address - Zip Code:38355-9702
Practice Address - Country:US
Practice Address - Phone:731-783-0777
Practice Address - Fax:731-783-3005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 332B00000X
TN40793336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
4437693OtherNCPDP PROVIDER IDENTIFICATION NUMBER