1033160668 NPI number — CLARKESVILLE DRUG INC

Table of content: (NPI 1033160668)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033160668 NPI number — CLARKESVILLE DRUG INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLARKESVILLE DRUG INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CLARKESVILLE DRUG
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033160668
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/06/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1659
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLARKESVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30523-0028
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-754-3763
Provider Business Mailing Address Fax Number:
706-839-1293

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
596 W LOUISE ST
Provider Second Line Business Practice Location Address:
STE D
Provider Business Practice Location Address City Name:
CLARKESVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30523-5849
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-754-3763
Provider Business Practice Location Address Fax Number:
706-839-1293
Provider Enumeration Date:
05/16/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LEDBETTER
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER AND CHIEF PHARMACIST
Authorized Official Telephone Number:
706-754-3763

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: PHRE007029 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2015959 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 00385371B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00385371A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".