Provider Demographics
NPI:1609955186
Name:FALLON FAMILY DRUG, INC.
Entity Type:Organization
Organization Name:FALLON FAMILY DRUG, INC.
Other - Org Name:FALLON FAMILY UNITED DRUG
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GRANT
Authorized Official - Middle Name:S
Authorized Official - Last Name:MOULTON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:775-426-9385
Mailing Address - Street 1:5424 OAKWOOD CIR
Mailing Address - Street 2:FALLON
Mailing Address - City:FALLON
Mailing Address - State:NV
Mailing Address - Zip Code:89406-4272
Mailing Address - Country:US
Mailing Address - Phone:775-426-9385
Mailing Address - Fax:
Practice Address - Street 1:325 11TH STREET, NUMBER 2
Practice Address - Street 2:
Practice Address - City:LOVELOCK
Practice Address - State:NV
Practice Address - Zip Code:89419
Practice Address - Country:US
Practice Address - Phone:775-273-1700
Practice Address - Fax:775-273-9013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy