Provider Demographics
NPI:1407931827
Name:PROFESSIONAL APOTHECARY, INC.
Entity Type:Organization
Organization Name:PROFESSIONAL APOTHECARY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BLAKE
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:256-362-8328
Mailing Address - Street 1:210 NORTH ST W
Mailing Address - Street 2:
Mailing Address - City:TALLADEGA
Mailing Address - State:AL
Mailing Address - Zip Code:35160-2083
Mailing Address - Country:US
Mailing Address - Phone:256-362-8328
Mailing Address - Fax:256-362-8361
Practice Address - Street 1:210 NORTH ST W
Practice Address - Street 2:
Practice Address - City:TALLADEGA
Practice Address - State:AL
Practice Address - Zip Code:35160-2083
Practice Address - Country:US
Practice Address - Phone:256-362-8328
Practice Address - Fax:256-362-8361
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51050787OtherBLUE CROSS ALABAMA
AL000050787Medicaid
AL000050787Medicaid