Provider Demographics
NPI:1407917461
Name:PAYLESS PHARMACY EXPRESS #2, INC
Entity Type:Organization
Organization Name:PAYLESS PHARMACY EXPRESS #2, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:D
Authorized Official - Last Name:CAMP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-355-1815
Mailing Address - Street 1:1517 MOULTON ST W
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35601-2149
Mailing Address - Country:US
Mailing Address - Phone:256-355-1815
Mailing Address - Fax:256-350-5300
Practice Address - Street 1:1517 MOULTON ST W
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35601-2149
Practice Address - Country:US
Practice Address - Phone:256-355-1815
Practice Address - Fax:256-350-5300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL110475333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL100002705Medicaid