Provider Demographics
NPI:1982929782
Name:LEESBURG PHARMACY, INC. DBA LOOKOUT MOUNTAIN PHARMACY
Entity type:Organization
Organization Name:LEESBURG PHARMACY, INC. DBA LOOKOUT MOUNTAIN PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:N
Authorized Official - Last Name:ST.CLAIR
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:256-526-6337
Mailing Address - Street 1:PO BOX 358
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:AL
Mailing Address - Zip Code:35983-0358
Mailing Address - Country:US
Mailing Address - Phone:256-526-6337
Mailing Address - Fax:256-526-6342
Practice Address - Street 1:1955 SAND ROCK AVE
Practice Address - Street 2:
Practice Address - City:SANDROCK
Practice Address - State:AL
Practice Address - Zip Code:35983-4327
Practice Address - Country:US
Practice Address - Phone:256-523-5665
Practice Address - Fax:256-523-5669
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LEESBURG PHARMACY, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-04-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL113381183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL113381OtherSTATE OF ALABAMA BOARD OF PHARMACY LICENSE #
ALFL1905465OtherDEA REGISTRATION