Provider Demographics
NPI:1659803658
Name:OZARK PHARMACY LLC
Entity Type:Organization
Organization Name:OZARK PHARMACY LLC
Other - Org Name:DALTON PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOE
Authorized Official - Middle Name:
Authorized Official - Last Name:DALTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-797-7992
Mailing Address - Street 1:PO BOX 279
Mailing Address - Street 2:
Mailing Address - City:SLOCOMB
Mailing Address - State:AL
Mailing Address - Zip Code:36375-0279
Mailing Address - Country:US
Mailing Address - Phone:334-886-2442
Mailing Address - Fax:
Practice Address - Street 1:940 E BROAD ST
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:AL
Practice Address - Zip Code:36360-1532
Practice Address - Country:US
Practice Address - Phone:334-803-8240
Practice Address - Fax:334-803-8218
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-29
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
AL1147043336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2168694OtherPK