Provider Demographics
NPI:1093726622
Name:MAGNOLIA SPRINGS PHARMACY LLC
Entity Type:Organization
Organization Name:MAGNOLIA SPRINGS PHARMACY LLC
Other - Org Name:MAGNOLIA SPRINGS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:SABRINA
Authorized Official - Middle Name:
Authorized Official - Last Name:CRUTCHFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:251-965-6273
Mailing Address - Street 1:PO BOX 1025
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA SPRINGS
Mailing Address - State:AL
Mailing Address - Zip Code:36555-1025
Mailing Address - Country:US
Mailing Address - Phone:251-965-6273
Mailing Address - Fax:251-965-6274
Practice Address - Street 1:12547 COUNTY ROAD 49
Practice Address - Street 2:
Practice Address - City:FOLEY
Practice Address - State:AL
Practice Address - Zip Code:36535-8437
Practice Address - Country:US
Practice Address - Phone:251-965-6273
Practice Address - Fax:251-965-6274
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2016-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
AL1125013336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1995406OtherPK
AL100039173Medicaid