Provider Demographics
NPI:1487206090
Name:MACK, ADAM
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:MACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1820 PEACHES LN
Mailing Address - Street 2:
Mailing Address - City:CANTONMENT
Mailing Address - State:FL
Mailing Address - Zip Code:32533-8500
Mailing Address - Country:US
Mailing Address - Phone:850-516-5477
Mailing Address - Fax:
Practice Address - Street 1:2 GREENO RD S
Practice Address - Street 2:
Practice Address - City:FAIRHOPE
Practice Address - State:AL
Practice Address - Zip Code:36532-2048
Practice Address - Country:US
Practice Address - Phone:251-928-6558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-13
Last Update Date:2019-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL209233336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy