Provider Demographics
NPI:1154642304
Name:TRUSSVILLE TOTAL CARE PHARMACY LLC
Entity Type:Organization
Organization Name:TRUSSVILLE TOTAL CARE PHARMACY LLC
Other - Org Name:CARROLL PHARMACY TRUSSVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:
Authorized Official - Last Name:CARROLL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:205-680-5557
Mailing Address - Street 1:PO BOX 252
Mailing Address - Street 2:
Mailing Address - City:CLAY
Mailing Address - State:AL
Mailing Address - Zip Code:35048-0252
Mailing Address - Country:US
Mailing Address - Phone:205-655-3455
Mailing Address - Fax:205-655-3425
Practice Address - Street 1:115 N CHALKVILLE RD
Practice Address - Street 2:
Practice Address - City:TRUSSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35173-1376
Practice Address - Country:US
Practice Address - Phone:205-655-3455
Practice Address - Fax:205-655-3425
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-22
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
163WD0400X, 261QM2500X, 333600000X
AL1134093336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes EducatorGroup - Multi-Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2125450OtherPK
AL000120600Medicaid