Provider Demographics
NPI:1437358751
Name:SHOALS FAMILY PHARMACY GROUP INC
Entity Type:Organization
Organization Name:SHOALS FAMILY PHARMACY GROUP INC
Other - Org Name:HOMETOWN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DEARMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-332-7400
Mailing Address - Street 1:609 GANDY ST NE
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35653-1911
Mailing Address - Country:US
Mailing Address - Phone:256-332-7400
Mailing Address - Fax:256-332-7490
Practice Address - Street 1:609 GANDY ST NE
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AL
Practice Address - Zip Code:35653-1911
Practice Address - Country:US
Practice Address - Phone:256-332-7400
Practice Address - Fax:256-332-7490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-16
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
AL1129713336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2123137OtherPK
AL115783Medicaid