Provider Demographics
NPI:1538663281
Name:BLACK BEAR PHARMACY, INC.
Entity Type:Organization
Organization Name:BLACK BEAR PHARMACY, INC.
Other - Org Name:PHD PHARMACY LTC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LOREN
Authorized Official - Middle Name:
Authorized Official - Last Name:PIERCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-474-7693
Mailing Address - Street 1:PO BOX 580
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-0580
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:110 KEITH ST SW STE 1AND2
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?:Yes
Parent Organization LBN:BLACK BEAR PHARMACY, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-03-19
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy