Provider Demographics
NPI:1588126809
Name:COOSA VALLEY APOTHECARY LL
Entity type:Organization
Organization Name:COOSA VALLEY APOTHECARY LL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROLAND
Authorized Official - Middle Name:
Authorized Official - Last Name:THACKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-401-4534
Mailing Address - Street 1:315 W HICKORY ST STE 150
Mailing Address - Street 2:
Mailing Address - City:SYLACAUGA
Mailing Address - State:AL
Mailing Address - Zip Code:35150-2913
Mailing Address - Country:US
Mailing Address - Phone:256-401-4534
Mailing Address - Fax:256-401-4603
Practice Address - Street 1:315 W HICKORY ST STE 150
Practice Address - Street 2:
Practice Address - City:SYLACAUGA
Practice Address - State:AL
Practice Address - Zip Code:35150-2913
Practice Address - Country:US
Practice Address - Phone:256-401-4534
Practice Address - Fax:256-401-4603
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-04
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy