NPIViewer - Provider NPI 1821362526

NPI:	1821362526
Name:	FOUNTAIN PLAZA PHARMACY LLC
Entity Type:	Organization
Organization Name:	FOUNTAIN PLAZA PHARMACY LLC
Other - Org Name:	FOUNTAINRX
Other - Org Type:	Doing Business As
Authorized Official - Title/Position:	PARTNER & CFO
Authorized Official - Prefix:
Authorized Official - First Name:	JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:	HUNTSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:	MBA MA
Authorized Official - Phone:	423-736-7976
Mailing Address - Street 1:	2825 W ANDREW JOHNSON HWY
Mailing Address - Street 2:
Mailing Address - City:	MORRISTOWN
Mailing Address - State:	TN
Mailing Address - Zip Code:	37814-3216
Mailing Address - Country:	US
Mailing Address - Phone:	423-307-5757
Mailing Address - Fax:	423-307-5241
Practice Address - Street 1:	2825 W ANDREW JOHNSON HWY
Practice Address - Street 2:
Practice Address - City:	MORRISTOWN
Practice Address - State:	TN
Practice Address - Zip Code:	37814
Practice Address - Country:	US
Practice Address - Phone:	423-307-5757
Practice Address - Fax:	423-307-5241
EIN:	<UNAVAIL>
Is Organization Subpart?:	No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:	2012-02-28
Last Update Date:	2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:

Primary?	Code	Type	Classification	Specialization
Yes	3336C0003X	Suppliers	Pharmacy	Community/Retail Pharmacy
No	3336C0004X	Suppliers	Pharmacy	Compounding Pharmacy
No	3336H0001X	Suppliers	Pharmacy	Home Infusion Therapy Pharmacy
No	3336M0002X	Suppliers	Pharmacy	Mail Order Pharmacy
Yes	3336S0011X	Suppliers	Pharmacy	Specialty Pharmacy

State	Identifier ID	ID Type	Issuer
SC	7Z1164	Medicaid
AZ	95213	Medicaid
IL	1821362526	Medicaid
	2134355	Other	PK
UT	4067029	Medicaid
IN	300047862	Medicaid
OH	431597	Medicaid
VA	2018228689	Medicaid
NC	574038	Medicaid
KY	7100373620	Medicaid
CO	9000202940	Medicaid
AR	232282407	Medicaid
PA	7Z1164	Medicaid
TN	Q035892	Medicaid
PA	103955980001	Medicaid