Provider Demographics
NPI:1336169606
Name:EAST ALABAMA MENTAL HEALTH-MENTAL RETARDATION BOARD INCORPOR
Entity Type:Organization
Organization Name:EAST ALABAMA MENTAL HEALTH-MENTAL RETARDATION BOARD INCORPOR
Other - Org Name:EAST ALABAMA MENTAL HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:COTNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-742-2700
Mailing Address - Street 1:2506 LAMBERT DR
Mailing Address - Street 2:
Mailing Address - City:OPELIKA
Mailing Address - State:AL
Mailing Address - Zip Code:36801-7237
Mailing Address - Country:US
Mailing Address - Phone:334-742-2733
Mailing Address - Fax:334-742-2833
Practice Address - Street 1:2506 LAMBERT DR
Practice Address - Street 2:
Practice Address - City:OPELIKA
Practice Address - State:AL
Practice Address - Zip Code:36801-7237
Practice Address - Country:US
Practice Address - Phone:334-742-2733
Practice Address - Fax:334-742-2833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
AL1145283336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2134256OtherPK
AL100002807Medicaid
J476Medicare PIN