Provider Demographics
NPI:1568874626
Name:OLD TOWN PHARMACY INC
Entity Type:Organization
Organization Name:OLD TOWN PHARMACY INC
Other - Org Name:OLD TOWN PHARMACY INC
Other - Org Type:Other Name
Authorized Official - Title/Position:BOOKKEEPER
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:HODGKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-758-6770
Mailing Address - Street 1:26064 SE HWY 19
Mailing Address - Street 2:
Mailing Address - City:OLD TOWN
Mailing Address - State:FL
Mailing Address - Zip Code:32680-3087
Mailing Address - Country:US
Mailing Address - Phone:352-542-9301
Mailing Address - Fax:352-542-9562
Practice Address - Street 1:26064 SE HWY 19
Practice Address - Street 2:
Practice Address - City:OLD TOWN
Practice Address - State:FL
Practice Address - Zip Code:32680
Practice Address - Country:US
Practice Address - Phone:352-542-9301
Practice Address - Fax:352-542-9865
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-23
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2144428OtherPK