Provider Demographics
NPI:1922105766
Name:UNIVERSITY OF ALABAMA AT BIRMINGHAM
Entity Type:Organization
Organization Name:UNIVERSITY OF ALABAMA AT BIRMINGHAM
Other - Org Name:KIRKLIN CLINIC PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF AMBULATORY OPERATI
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:205-934-7862
Mailing Address - Street 1:2000 6TH AVE S
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35233-2110
Mailing Address - Country:US
Mailing Address - Phone:205-801-8730
Mailing Address - Fax:205-801-8902
Practice Address - Street 1:2000 6TH AVE S
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35233-2110
Practice Address - Country:US
Practice Address - Phone:205-801-8730
Practice Address - Fax:205-801-8902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2016-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0003X, 3336M0002X, 3336S0011X
AL1111763336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL100010013Medicaid
1992704OtherPK
1992704OtherPK