Provider Demographics
NPI:1245344456
Name:MEDI-AGE PHARMACEUTICALS INC
Entity type:Organization
Organization Name:MEDI-AGE PHARMACEUTICALS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:RICKY
Authorized Official - Middle Name:A
Authorized Official - Last Name:BEARDEN
Authorized Official - Suffix:
Authorized Official - Credentials:R PH
Authorized Official - Phone:256-538-5850
Mailing Address - Street 1:1433 3RD ST SW
Mailing Address - Street 2:P.O. BOX 490
Mailing Address - City:ATTALLA
Mailing Address - State:AL
Mailing Address - Zip Code:35954-1132
Mailing Address - Country:US
Mailing Address - Phone:256-538-5850
Mailing Address - Fax:256-538-1860
Practice Address - Street 1:1433 3RD ST SW
Practice Address - Street 2:
Practice Address - City:ATTALLA
Practice Address - State:AL
Practice Address - Zip Code:35954-1132
Practice Address - Country:US
Practice Address - Phone:256-538-5850
Practice Address - Fax:256-538-1860
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2012-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1084533336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL100001978Medicaid
NCPDPOtherNATIONAL PHARMACY PROVIDE