Provider Demographics
NPI:1942528278
Name:PEACOCK PHARMACY LLC
Entity Type:Organization
Organization Name:PEACOCK PHARMACY LLC
Other - Org Name:PEACOCK PHARMACY,LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:DIANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-596-4501
Mailing Address - Street 1:1201 HIGHWAY 37 19E
Mailing Address - Street 2:SUITE 3
Mailing Address - City:ELIZABETHTON
Mailing Address - State:TN
Mailing Address - Zip Code:37643-4678
Mailing Address - Country:US
Mailing Address - Phone:423-542-2195
Mailing Address - Fax:
Practice Address - Street 1:550 S CHURCH ST STE 9
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29306-3306
Practice Address - Country:US
Practice Address - Phone:864-596-4501
Practice Address - Fax:864-596-4503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-11
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336M0002X
SC109933336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4229680OtherNCPDP PROVIDER IDENTIFICATION NUMBER