Provider Demographics
NPI:1841206570
Name:BROWN DRUG CO INC
Entity Type:Organization
Organization Name:BROWN DRUG CO INC
Other - Org Name:DALLAS AVENUE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:L
Authorized Official - Last Name:GIBBS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-872-3255
Mailing Address - Street 1:1402 W DALLAS AVE
Mailing Address - Street 2:
Mailing Address - City:SELMA
Mailing Address - State:AL
Mailing Address - Zip Code:36701-7017
Mailing Address - Country:US
Mailing Address - Phone:334-872-3255
Mailing Address - Fax:334-874-9453
Practice Address - Street 1:1402 W DALLAS AVE
Practice Address - Street 2:
Practice Address - City:SELMA
Practice Address - State:AL
Practice Address - Zip Code:36701-7017
Practice Address - Country:US
Practice Address - Phone:334-872-3255
Practice Address - Fax:334-874-9453
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
AL1030153336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL100002422Medicaid
0123430OtherNCPDP PROVIDER IDENTIFICATION NUMBER
AL100002422Medicaid