Provider Demographics
NPI:1154667970
Name:COPELAND PHARMACEUTICAL SERVICES LLC
Entity Type:Organization
Organization Name:COPELAND PHARMACEUTICAL SERVICES LLC
Other - Org Name:CITY PHARMACY OF RUSSELLVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GRANT
Authorized Official - Middle Name:
Authorized Official - Last Name:COPELAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-616-3311
Mailing Address - Street 1:104 OLD CAPE DR
Mailing Address - Street 2:
Mailing Address - City:TUSCUMBIA
Mailing Address - State:AL
Mailing Address - Zip Code:35674-5216
Mailing Address - Country:US
Mailing Address - Phone:256-616-3311
Mailing Address - Fax:256-389-2992
Practice Address - Street 1:14001 HIGHWAY 43
Practice Address - Street 2:STE 13
Practice Address - City:RUSSELLVILLE
Practice Address - State:AL
Practice Address - Zip Code:35653-2848
Practice Address - Country:US
Practice Address - Phone:256-331-1919
Practice Address - Fax:256-331-1960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-26
Last Update Date:2013-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1140223336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL144805Medicaid
2138439OtherPK