Provider Demographics
NPI:1124203211
Name:FORT DEPOSIT DRUG PHARMACY LLC
Entity Type:Organization
Organization Name:FORT DEPOSIT DRUG PHARMACY LLC
Other - Org Name:FORT DEPOSIT DRUG PHARMACY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-401-7911
Mailing Address - Street 1:PO BOX 280
Mailing Address - Street 2:
Mailing Address - City:FORT DEPOSIT
Mailing Address - State:AL
Mailing Address - Zip Code:36032-0280
Mailing Address - Country:US
Mailing Address - Phone:334-227-7777
Mailing Address - Fax:334-227-4466
Practice Address - Street 1:120 S POLLARD ST
Practice Address - Street 2:
Practice Address - City:FORT DEPOSIT
Practice Address - State:AL
Practice Address - Zip Code:36032-3825
Practice Address - Country:US
Practice Address - Phone:334-227-7777
Practice Address - Fax:334-227-4466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-08
Last Update Date:2011-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1130133336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0135029OtherNCPDP PROVIDER IDENTIFICATION NUMBER
AL113013Medicaid