Provider Demographics
NPI:1700183753
Name:ABBEVILLE PHARMACY LLC
Entity Type:Organization
Organization Name:ABBEVILLE PHARMACY LLC
Other - Org Name:DALTON PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOE
Authorized Official - Middle Name:
Authorized Official - Last Name:DALTON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:334-585-0246
Mailing Address - Street 1:615 OZARK RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:ABBEVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36310-2629
Mailing Address - Country:US
Mailing Address - Phone:334-585-0246
Mailing Address - Fax:334-585-0336
Practice Address - Street 1:615 OZARK RD
Practice Address - Street 2:SUITE B
Practice Address - City:ABBEVILLE
Practice Address - State:AL
Practice Address - Zip Code:36310-2629
Practice Address - Country:US
Practice Address - Phone:334-585-0246
Practice Address - Fax:334-585-0336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-26
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
AL1134923336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2129040OtherPK
AL126466Medicaid