Provider Demographics
NPI:1770055329
Name:SMALL TOWN PHARMACY, LLC
Entity type:Organization
Organization Name:SMALL TOWN PHARMACY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:CLAIRE
Authorized Official - Last Name:RICHARDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-696-5400
Mailing Address - Street 1:61 S BELLS ST
Mailing Address - Street 2:
Mailing Address - City:ALAMO
Mailing Address - State:TN
Mailing Address - Zip Code:38001-1768
Mailing Address - Country:US
Mailing Address - Phone:731-696-5400
Mailing Address - Fax:731-696-5405
Practice Address - Street 1:61 S BELLS ST
Practice Address - Street 2:
Practice Address - City:ALAMO
Practice Address - State:TN
Practice Address - Zip Code:38001-1768
Practice Address - Country:US
Practice Address - Phone:731-696-5400
Practice Address - Fax:731-696-5405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-20
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ047713Medicaid