Provider Demographics
NPI:1952773814
Name:MIKES PHARMACY OF HEADLAND INC
Entity Type:Organization
Organization Name:MIKES PHARMACY OF HEADLAND INC
Other - Org Name:MIKE'S PHARMACY OF HEADLAND,INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PITZING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-701-9549
Mailing Address - Street 1:202 HOLMAN DR
Mailing Address - Street 2:
Mailing Address - City:HEADLAND
Mailing Address - State:AL
Mailing Address - Zip Code:36345-2307
Mailing Address - Country:US
Mailing Address - Phone:334-693-3324
Mailing Address - Fax:334-693-5051
Practice Address - Street 1:202 HOLMAN DR
Practice Address - Street 2:
Practice Address - City:HEADLAND
Practice Address - State:AL
Practice Address - Zip Code:36345-2307
Practice Address - Country:US
Practice Address - Phone:334-693-3324
Practice Address - Fax:334-693-5051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-30
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
AL1145353336C0003X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1952773814Medicaid
2154941OtherPK