Provider Demographics
NPI:1710071873
Name:ELBERTA PHARMACY, INC.
Entity Type:Organization
Organization Name:ELBERTA PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:TONJA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:LOWERY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:251-986-8115
Mailing Address - Street 1:PO DRAWER 670
Mailing Address - Street 2:
Mailing Address - City:ELBERTA
Mailing Address - State:AL
Mailing Address - Zip Code:36530-0670
Mailing Address - Country:US
Mailing Address - Phone:251-986-8115
Mailing Address - Fax:251-986-3062
Practice Address - Street 1:24980 STATE ST
Practice Address - Street 2:
Practice Address - City:ELBERTA
Practice Address - State:AL
Practice Address - Zip Code:36530-0670
Practice Address - Country:US
Practice Address - Phone:251-986-8115
Practice Address - Fax:251-986-3062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL4732150001Medicare ID - Type UnspecifiedMEDICARE ID