Provider Demographics
NPI:1093829061
Name:FAMILY MEDICINE PHARMACY LLC
Entity Type:Organization
Organization Name:FAMILY MEDICINE PHARMACY LLC
Other - Org Name:FAMILY MEDICINE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:WISE
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:334-636-9809
Mailing Address - Street 1:470 SAFFORD AVE W
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36784-3112
Mailing Address - Country:US
Mailing Address - Phone:334-636-9809
Mailing Address - Fax:334-636-9807
Practice Address - Street 1:470 SAFFORD AVE W
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:AL
Practice Address - Zip Code:36784-3112
Practice Address - Country:US
Practice Address - Phone:334-636-9809
Practice Address - Fax:334-636-9807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
AL1038693336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1991227OtherPK
AL124922Medicaid