Provider Demographics
NPI:1831104462
Name:PCM PHARMACY
Entity Type:Organization
Organization Name:PCM PHARMACY
Other - Org Name:PROFESSIONAL CUSTOMIZED MEDICATIONS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MGR MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:256-757-1956
Mailing Address - Street 1:PO BOX 99
Mailing Address - Street 2:
Mailing Address - City:KILLEN
Mailing Address - State:AL
Mailing Address - Zip Code:35645-0099
Mailing Address - Country:US
Mailing Address - Phone:256-757-1956
Mailing Address - Fax:256-757-1936
Practice Address - Street 1:1621 HIGHWAY 72
Practice Address - Street 2:
Practice Address - City:KILLEN
Practice Address - State:AL
Practice Address - Zip Code:35645-9142
Practice Address - Country:US
Practice Address - Phone:256-757-1956
Practice Address - Fax:256-757-1936
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
AL1115383336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL100003101Medicaid
0129191OtherNCPDP PROVIDER IDENTIFICATION NUMBER
1281490001Medicare NSC