Provider Demographics
NPI:1396151924
Name:BREWTON MEDICAL CENTER PHARMACY PC
Entity type:Organization
Organization Name:BREWTON MEDICAL CENTER PHARMACY PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:COTTRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-802-0387
Mailing Address - Street 1:174 HIGHWAY 113
Mailing Address - Street 2:
Mailing Address - City:FLOMATON
Mailing Address - State:AL
Mailing Address - Zip Code:36441-4556
Mailing Address - Country:US
Mailing Address - Phone:251-867-5454
Mailing Address - Fax:251-867-6117
Practice Address - Street 1:174 HIGHWAY 113
Practice Address - Street 2:
Practice Address - City:FLOMATON
Practice Address - State:AL
Practice Address - Zip Code:36441-4556
Practice Address - Country:US
Practice Address - Phone:251-867-5454
Practice Address - Fax:251-867-6117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-02
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
AL1143833336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL163523Medicaid
2146701OtherPK