Provider Demographics
NPI:1770050965
Name:OLD TOWN PHARMACY INC
Entity type:Organization
Organization Name:OLD TOWN PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOOKKEEPER
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:HODGKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-758-6770
Mailing Address - Street 1:1756 SW BARNETT WAY
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-6953
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:26064 US- 19
Practice Address - Street 2:
Practice Address - City:OLD TOWN
Practice Address - State:FL
Practice Address - Zip Code:32680
Practice Address - Country:US
Practice Address - Phone:386-758-6770
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-26
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy