Provider Demographics
NPI:1003821612
Name:CARROLLTON PRESCRIPTION SHOP INC
Entity type:Organization
Organization Name:CARROLLTON PRESCRIPTION SHOP INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:SOUTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-494-7150
Mailing Address - Street 1:41254 HIGHWAY 195
Mailing Address - Street 2:SUITE G
Mailing Address - City:HALEYVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35565-8114
Mailing Address - Country:US
Mailing Address - Phone:205-494-7150
Mailing Address - Fax:205-485-1133
Practice Address - Street 1:41254 HIGHWAY 195 STE G
Practice Address - Street 2:
Practice Address - City:HALEYVILLE
Practice Address - State:AL
Practice Address - Zip Code:35565-8115
Practice Address - Country:US
Practice Address - Phone:205-494-7150
Practice Address - Fax:205-485-1130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
AL109667333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2152742OtherPK
AL100001842Medicaid