Marble City Pharmacy, Inc.

Contacts

Phone	+1 256-245-4446
Fax	2562454484

Authorized person

Name	MR. JACOB MILES JOHNSON
Role	OWNER
Phone	2562454446

Taxonomy

Taxonomy Code	183500000X - Pharmacist
License Number	112273
State	AL
Is Primary	Yes
Taxonomy Code	332B00000X - Durable Medical Equipment & Medical Supplies
License Number	112273
State	AL
Is Primary	No

Other Provider Identifiers

Issuer	NABP
Number	0131730
State	AL
Issuer	MEDICAID
Number	100003479
State	AL
Issuer	MEDICAID
Number	009932695
State	AL

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2019-01-01
Business code	446110
Sponsor’s telephone number	2562454446
Plan sponsor’s address	264 W. FORT WILLIAMS ST., SYLACAUGA, AL, 35150

Signature of

Role	Plan administrator
Date	2024-05-22
Name of individual signing	JARED JOHNSON

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2019-01-01
Business code	446110
Sponsor’s telephone number	2562454446
Plan sponsor’s address	264 W. FORT WILLIAMS ST., SYLACAUGA, AL, 35150

Signature of

Role	Plan administrator
Date	2023-07-19
Name of individual signing	JARED JOHNSON

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2019-01-01
Business code	446110
Sponsor’s telephone number	2562454446
Plan sponsor’s address	264 W. FORT WILLIAMS ST., SYLACAUGA, AL, 35150

Signature of

Role	Plan administrator
Date	2022-07-25
Name of individual signing	JARED JOHNSON

File	View Page
Three-digit plan number (PN)	951
Effective date of plan	2020-10-01
Business code	446110
Sponsor’s telephone number	2059561836
Plan sponsor’s address	264 W. FORT WILLIAMS STREET, SYLACAUGA, AL, 35150

Plan administrator’s name and address

Administrator’s EIN	472506773
Plan administrator’s name	KENNION & CO, LLC
Plan administrator’s address	2828 OLD 280 COURT, SUITE 110, VESTAVIA, AL, 35243
Administrator’s telephone number	8669665457

Signature of

Role	Plan administrator
Date	2022-07-21
Name of individual signing	W. HAL SHEPHERD
Role	Employer/plan sponsor
Date	2022-07-21
Name of individual signing	W. HAL SHEPHERD

File	View Page
Three-digit plan number (PN)	951
Effective date of plan	2020-10-01
Business code	446110
Sponsor’s telephone number	2059561836
Plan sponsor’s address	264 W. FORT WILLIAMS STREET, SYLACAUGA, AL, 35150

Plan administrator’s name and address

Administrator’s EIN	472506773
Plan administrator’s name	KENNION & CO, LLC
Plan administrator’s address	2828 OLD 280 COURT, SUITE 110, VESTAVIA, AL, 35243
Administrator’s telephone number	8669665457

Signature of

Role	Plan administrator
Date	2021-10-09
Name of individual signing	W. HAL SHEPHERD
Role	Employer/plan sponsor
Date	2021-10-09
Name of individual signing	W. HAL SHEPHERD

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2019-01-01
Business code	446110
Sponsor’s telephone number	2562454446
Plan sponsor’s address	264 W. FORT WILLIAMS ST., SYLACAUGA, AL, 35150

Signature of

Role	Plan administrator
Date	2021-07-27
Name of individual signing	JARED JOHNSON

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2019-01-01
Business code	446110
Sponsor’s telephone number	2562454446
Plan sponsor’s address	264 W. FORT WILLIAMS ST., SYLACAUGA, AL, 35150