Provider Demographics
NPI:1013032648
Name:MOUNDVILLE MEDICAL PLAZA INC.
Entity Type:Organization
Organization Name:MOUNDVILLE MEDICAL PLAZA INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CLIFFORD
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:HARLAND
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:205-371-9031
Mailing Address - Street 1:16061 HWY 69 SOUTH
Mailing Address - Street 2:P.O. BOX 551
Mailing Address - City:MOUNDVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35474
Mailing Address - Country:US
Mailing Address - Phone:205-371-9031
Mailing Address - Fax:205-371-9074
Practice Address - Street 1:16061 HWY 69 SOUTH
Practice Address - Street 2:
Practice Address - City:MOUNDVILLE
Practice Address - State:AL
Practice Address - Zip Code:35474
Practice Address - Country:US
Practice Address - Phone:205-371-9031
Practice Address - Fax:205-371-9074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL100001507Medicaid
0498260001Medicare NSC