Provider Demographics
NPI:1982094736
Name:PHILLIPS, PATRICK (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10639 AL HIGHWAY 168
Mailing Address - Street 2:
Mailing Address - City:BOAZ
Mailing Address - State:AL
Mailing Address - Zip Code:35957-1955
Mailing Address - Country:US
Mailing Address - Phone:256-593-5279
Mailing Address - Fax:256-593-1991
Practice Address - Street 1:10639 AL HIGHWAY 168
Practice Address - Street 2:
Practice Address - City:BOAZ
Practice Address - State:AL
Practice Address - Zip Code:35957-1955
Practice Address - Country:US
Practice Address - Phone:256-593-5279
Practice Address - Fax:256-593-1991
Is Sole Proprietor?:No
Enumeration Date:2015-02-02
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL15247183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL100003151Medicaid