Provider Demographics
NPI:1689858821
Name:HOMETOWN PHARMACY OF MEDINA LLC
Entity Type:Organization
Organization Name:HOMETOWN PHARMACY OF MEDINA LLC
Other - Org Name:HOMETOWN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:J
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:BOWERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-783-0777
Mailing Address - Street 1:PO BOX 310
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:TN
Mailing Address - Zip Code:38355
Mailing Address - Country:US
Mailing Address - Phone:731-783-0777
Mailing Address - Fax:731-783-3005
Practice Address - Street 1:609 HWY 45 BYPASS
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:TN
Practice Address - Zip Code:38355
Practice Address - Country:US
Practice Address - Phone:731-783-0777
Practice Address - Fax:731-783-3005
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HOMETOWN PHARMACY OF MEDINA LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-24
Last Update Date:2007-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
5313880001Medicare NSC