Provider Demographics
NPI:1265754030
Name:P H PHARMACY LLC
Entity type:Organization
Organization Name:P H PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:HUNTER
Authorized Official - Middle Name:
Authorized Official - Last Name:HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-845-9470
Mailing Address - Street 1:110 KEITH ST SW
Mailing Address - Street 2:SUITE 3
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37311-5868
Mailing Address - Country:US
Mailing Address - Phone:423-614-6610
Mailing Address - Fax:888-805-2406
Practice Address - Street 1:110 KEITH ST SW
Practice Address - Street 2:STE 3
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37311-5868
Practice Address - Country:US
Practice Address - Phone:423-614-6610
Practice Address - Fax:888-805-2406
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-22
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHNR000227332B00000X
TN4732333600000X
FLPH287183336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1265754030Medicaid
2123882OtherPK