Provider Demographics
NPI:1487211058
Name:BLACK BEAR PHARMACY, INC.
Entity Type:Organization
Organization Name:BLACK BEAR PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COMPLIANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:LAMB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-474-7693
Mailing Address - Street 1:106 ROCK QUARRY RD STE B
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-3766
Mailing Address - Country:US
Mailing Address - Phone:770-474-7693
Mailing Address - Fax:
Practice Address - Street 1:110 KEITH ST SW STE 1&2
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37311-5868
Practice Address - Country:US
Practice Address - Phone:423-614-6650
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-20
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy