1285050823 NPI number — DULUTH PHARMACY LLC

Table of content: (NPI 1285050823)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285050823 NPI number — DULUTH PHARMACY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DULUTH PHARMACY LLC
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:
DULUTH PHARMACY
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:
1285050823
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/09/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3890 PLEASANT HILL RD STE 101B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DULUTH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30096-4807
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
177-047-6282
Provider Business Mailing Address Fax Number:
770-476-2811

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3890 PLEASANT HILL RD STE 103
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DULUTH
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30096-4807
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-476-2820
Provider Business Practice Location Address Fax Number:
770-476-2811
Provider Enumeration Date:
03/06/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
JAYANTHI
Authorized Official First Name:
BADRINATH
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACIST
Authorized Official Telephone Number:
678-254-9200

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  PHRE009996 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 003145071A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".