Provider Demographics
NPI:1447528492
Name:GARDENDALE PHARMACY LLC
Entity type:Organization
Organization Name:GARDENDALE PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:
Authorized Official - Last Name:SPEEGLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-487-3079
Mailing Address - Street 1:210 FIELDSTOWN RD
Mailing Address - Street 2:
Mailing Address - City:GARDENDALE
Mailing Address - State:AL
Mailing Address - Zip Code:35071-2408
Mailing Address - Country:US
Mailing Address - Phone:205-285-8135
Mailing Address - Fax:205-487-3079
Practice Address - Street 1:210 FIELDSTOWN RD
Practice Address - Street 2:
Practice Address - City:GARDENDALE
Practice Address - State:AL
Practice Address - Zip Code:35071-2408
Practice Address - Country:US
Practice Address - Phone:205-285-8135
Practice Address - Fax:205-487-3079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-06
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1138423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0137453OtherNCPDP PROVIDER IDENTIFICATION NUMBER