Provider Demographics
NPI:1740474204
Name:FAYETTE PHARMACY INC
Entity type:Organization
Organization Name:FAYETTE PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:SUMMER
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-712-1685
Mailing Address - Street 1:PO BOX 408
Mailing Address - Street 2:
Mailing Address - City:MILLPORT
Mailing Address - State:AL
Mailing Address - Zip Code:35576-0408
Mailing Address - Country:US
Mailing Address - Phone:205-662-3817
Mailing Address - Fax:205-662-4757
Practice Address - Street 1:13532 HIGHWAY 96
Practice Address - Street 2:
Practice Address - City:MILLPORT
Practice Address - State:AL
Practice Address - Zip Code:35576-2522
Practice Address - Country:US
Practice Address - Phone:205-662-3817
Practice Address - Fax:205-662-4757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-28
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
AL1056453336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2138253OtherPK