Provider Demographics
NPI:1366914202
Name:DADEVILLE PHARMACY LLC
Entity type:Organization
Organization Name:DADEVILLE PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOE
Authorized Official - Middle Name:A
Authorized Official - Last Name:DALTON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:334-797-7992
Mailing Address - Street 1:PO BOX 279
Mailing Address - Street 2:
Mailing Address - City:SLOCOMB
Mailing Address - State:AL
Mailing Address - Zip Code:36375-0279
Mailing Address - Country:US
Mailing Address - Phone:334-797-7992
Mailing Address - Fax:256-825-5584
Practice Address - Street 1:221 E SOUTH ST
Practice Address - Street 2:
Practice Address - City:DADEVILLE
Practice Address - State:AL
Practice Address - Zip Code:36853-1923
Practice Address - Country:US
Practice Address - Phone:256-825-0063
Practice Address - Fax:256-825-5584
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-17
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL226751Medicaid