Provider Demographics
NPI:1417954488
Name:MARBLE CITY PHARMACY INC
Entity Type:Organization
Organization Name:MARBLE CITY PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:MILES
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:256-245-4446
Mailing Address - Street 1:264 W FORT WILLIAMS ST
Mailing Address - Street 2:
Mailing Address - City:SYLACAUGA
Mailing Address - State:AL
Mailing Address - Zip Code:35150-2432
Mailing Address - Country:US
Mailing Address - Phone:256-245-4446
Mailing Address - Fax:256-245-4484
Practice Address - Street 1:264 W FORT WILLIAMS ST
Practice Address - Street 2:
Practice Address - City:SYLACAUGA
Practice Address - State:AL
Practice Address - Zip Code:35150-2432
Practice Address - Country:US
Practice Address - Phone:256-245-4446
Practice Address - Fax:256-245-4484
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-05
Last Update Date:2010-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL112273183500000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL0131730OtherNABP
AL100003479Medicaid
AL009932695Medicaid
AL009932695Medicaid