Provider Demographics
NPI:1952612848
Name:PEACOCK PHARMACY LLC
Entity Type:Organization
Organization Name:PEACOCK PHARMACY LLC
Other - Org Name:PEACOCK PHARMACY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:
Authorized Official - Last Name:WELLINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-547-3224
Mailing Address - Street 1:1201 HWY 19E BYASS
Mailing Address - Street 2:SUITE 3
Mailing Address - City:ELIZABETHTON
Mailing Address - State:TN
Mailing Address - Zip Code:37643
Mailing Address - Country:US
Mailing Address - Phone:423-547-3224
Mailing Address - Fax:800-419-1565
Practice Address - Street 1:2099 E MAIN ST STE G
Practice Address - Street 2:
Practice Address - City:DUNCAN
Practice Address - State:SC
Practice Address - Zip Code:29334-8886
Practice Address - Country:US
Practice Address - Phone:864-486-8252
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-25
Last Update Date:2010-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4229767OtherNCPDP PROVIDER IDENTIFICATION NUMBER