Provider Demographics
NPI:1063824787
Name:COASTAL CARE PHARMACY LLC
Entity Type:Organization
Organization Name:COASTAL CARE PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:J
Authorized Official - Last Name:SHIRLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-246-2491
Mailing Address - Street 1:7895 HIGHWAY 119
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ALABASTER
Mailing Address - State:AL
Mailing Address - Zip Code:35007
Mailing Address - Country:US
Mailing Address - Phone:850-346-8868
Mailing Address - Fax:
Practice Address - Street 1:11939 PANAMA CITY BEACH PKWY
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32407-2605
Practice Address - Country:US
Practice Address - Phone:850-346-8868
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-29
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH281723336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL114497OtherALABAMA BOARD OF PHARMACY PERMIT