Provider Demographics
NPI:1558376178
Name:CHARLES R SPIVEY, INC.
Entity Type:Organization
Organization Name:CHARLES R SPIVEY, INC.
Other - Org Name:GREENE SUPER DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:SPIVEY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:334-644-3154
Mailing Address - Street 1:701 N GILMER AVE
Mailing Address - Street 2:
Mailing Address - City:LANETT
Mailing Address - State:AL
Mailing Address - Zip Code:36863-2081
Mailing Address - Country:US
Mailing Address - Phone:334-644-3154
Mailing Address - Fax:334-644-5600
Practice Address - Street 1:701 N GILMER AVE
Practice Address - Street 2:
Practice Address - City:LANETT
Practice Address - State:AL
Practice Address - Zip Code:36863-2081
Practice Address - Country:US
Practice Address - Phone:334-644-3154
Practice Address - Fax:334-644-5600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
AL1047103336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000135671AMedicaid
1988802OtherPK
AL100003681Medicaid