Provider Demographics
NPI:1417372046
Name:HEAVENLY CARE PHARMACY LLC
Entity Type:Organization
Organization Name:HEAVENLY CARE PHARMACY LLC
Other - Org Name:HEAVENLY CARE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SANTONIA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVISON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:205-434-1427
Mailing Address - Street 1:PO BOX 1686
Mailing Address - Street 2:
Mailing Address - City:BESSEMER
Mailing Address - State:AL
Mailing Address - Zip Code:35021-1686
Mailing Address - Country:US
Mailing Address - Phone:205-434-1427
Mailing Address - Fax:205-565-8329
Practice Address - Street 1:617 9TH AVE N
Practice Address - Street 2:
Practice Address - City:BESSEMER
Practice Address - State:AL
Practice Address - Zip Code:35020-5368
Practice Address - Country:US
Practice Address - Phone:205-434-1427
Practice Address - Fax:205-565-8329
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-18
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
AL1143003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL158195Medicaid
2144363OtherPK