Provider Demographics
NPI:1689808917
Name:FORT WILLIAMS PHARMACY, LLC
Entity Type:Organization
Organization Name:FORT WILLIAMS PHARMACY, LLC
Other - Org Name:FORT WILLIAMS PHARMACY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:LIGHTSEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-404-6165
Mailing Address - Street 1:401 W FORT WILLIAMS ST
Mailing Address - Street 2:
Mailing Address - City:SYLACAUGA
Mailing Address - State:AL
Mailing Address - Zip Code:35150-2435
Mailing Address - Country:US
Mailing Address - Phone:256-207-2007
Mailing Address - Fax:256-207-2008
Practice Address - Street 1:401 W FORT WILLIAMS ST
Practice Address - Street 2:
Practice Address - City:SYLACAUGA
Practice Address - State:AL
Practice Address - Zip Code:35150-2435
Practice Address - Country:US
Practice Address - Phone:256-207-2007
Practice Address - Fax:256-207-2008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-14
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
AL1132733336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2120344OtherPK