Provider Demographics
NPI:1760996573
Name:DOTHAN PHARMACY INC
Entity Type:Organization
Organization Name:DOTHAN PHARMACY INC
Other - Org Name:DOTHAN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:334-479-8448
Mailing Address - Street 1:301 W INEZ RD STE 8
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-5678
Mailing Address - Country:US
Mailing Address - Phone:334-479-8448
Mailing Address - Fax:334-479-8108
Practice Address - Street 1:301 W INEZ RD STE 8
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-5678
Practice Address - Country:US
Practice Address - Phone:334-479-8448
Practice Address - Fax:334-479-8108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-01
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1147673336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2174323OtherPK
AL207314Medicaid