Provider Demographics
NPI:1922177815
Name:MALLETTE DRUG COMPANY INC
Entity Type:Organization
Organization Name:MALLETTE DRUG COMPANY INC
Other - Org Name:MALLETTE DRUG COMPANY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRES
Authorized Official - Prefix:
Authorized Official - First Name:BOBBY
Authorized Official - Middle Name:
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:334-222-1141
Mailing Address - Street 1:PO BOX 327
Mailing Address - Street 2:
Mailing Address - City:ANDALUSIA
Mailing Address - State:AL
Mailing Address - Zip Code:36420-1205
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:837 S THREE NOTCH ST
Practice Address - Street 2:
Practice Address - City:ANDALUSIA
Practice Address - State:AL
Practice Address - Zip Code:36420-5321
Practice Address - Country:US
Practice Address - Phone:334-222-1141
Practice Address - Fax:334-222-8361
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2009-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
AL1064703336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0103779OtherNCPDP PROVIDER IDENTIFICATION NUMBER
AL100000373Medicaid
AL100000373Medicaid