Provider Demographics
NPI:1316026164
Name:CLOVERLAND DRUG, INC
Entity Type:Organization
Organization Name:CLOVERLAND DRUG, INC
Other - Org Name:FOUNTAIN CITY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:SAALWAECHTER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:334-322-2927
Mailing Address - Street 1:PO BOX 240817
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36124-0817
Mailing Address - Country:US
Mailing Address - Phone:334-386-2742
Mailing Address - Fax:334-386-2745
Practice Address - Street 1:105 N MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:PRATTVILLE
Practice Address - State:AL
Practice Address - Zip Code:36067-3332
Practice Address - Country:US
Practice Address - Phone:334-365-3327
Practice Address - Fax:334-365-3316
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL104085333600000X
3336C0003X, 3336C0004X, 3336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes333600000XSuppliersPharmacyGroup - Single Specialty
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2143927OtherPK
AL156110Medicaid