Provider Demographics
NPI:1194005918
Name:WETUMPKA PHARMACY
Entity type:Organization
Organization Name:WETUMPKA PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LATORRE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:334-567-5442
Mailing Address - Street 1:277 HUNTRESS ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WETUMPKA
Mailing Address - State:AL
Mailing Address - Zip Code:36092
Mailing Address - Country:US
Mailing Address - Phone:334-567-5442
Mailing Address - Fax:334-567-5423
Practice Address - Street 1:277 HUNTRESS ST
Practice Address - Street 2:SUITE 101
Practice Address - City:WETUMPKA
Practice Address - State:AL
Practice Address - Zip Code:36092
Practice Address - Country:US
Practice Address - Phone:334-567-5442
Practice Address - Fax:334-567-5423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-24
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
AL1137923336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2131485OtherPK