Provider Demographics
NPI:1467766865
Name:NEW GRAND BAY PHARMACY, LLC
Entity Type:Organization
Organization Name:NEW GRAND BAY PHARMACY, LLC
Other - Org Name:GRAND BAY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:D
Authorized Official - Last Name:COTTRELL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:251-865-5555
Mailing Address - Street 1:PO BOX 129
Mailing Address - Street 2:
Mailing Address - City:GRAND BAY
Mailing Address - State:AL
Mailing Address - Zip Code:36541-0129
Mailing Address - Country:US
Mailing Address - Phone:251-865-1040
Mailing Address - Fax:251-865-1041
Practice Address - Street 1:10067 GRAND BAY WILMER RD S
Practice Address - Street 2:
Practice Address - City:GRAND BAY
Practice Address - State:AL
Practice Address - Zip Code:36541-5003
Practice Address - Country:US
Practice Address - Phone:251-865-5555
Practice Address - Fax:251-865-3785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-28
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1134153336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy