Provider Demographics
NPI:1235240532
Name:LOCUST FORK PHARMACY, LLC
Entity Type:Organization
Organization Name:LOCUST FORK PHARMACY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST AND OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHNNY
Authorized Official - Middle Name:HOYT
Authorized Official - Last Name:CLEVELAND
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:205-680-2222
Mailing Address - Street 1:PO BOX 52
Mailing Address - Street 2:
Mailing Address - City:LOCUST FORK
Mailing Address - State:AL
Mailing Address - Zip Code:35097-0052
Mailing Address - Country:US
Mailing Address - Phone:205-680-2222
Mailing Address - Fax:205-680-2200
Practice Address - Street 1:29984 STATE HIGHWAY 79
Practice Address - Street 2:SUITE 600
Practice Address - City:LOCUST FORK
Practice Address - State:AL
Practice Address - Zip Code:35097-5878
Practice Address - Country:US
Practice Address - Phone:205-680-2222
Practice Address - Fax:205-680-2200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL13351183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty