1831293885 NPI number — NAS DECATUR LLC

Table of content: (NPI 1831293885)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831293885 NPI number — NAS DECATUR LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NAS DECATUR 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:
MCKINNEY'S APOTHECARY
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:
1831293885
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/02/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
225 E PONCE DE LEON AVE
Provider Second Line Business Mailing Address:
SUITE 140
Provider Business Mailing Address City Name:
DECATUR
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30030-3444
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-378-5408
Provider Business Mailing Address Fax Number:
404-378-5400

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
225 E PONCE DE LEON AVE
Provider Second Line Business Practice Location Address:
SUITE 140
Provider Business Practice Location Address City Name:
DECATUR
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30030-3444
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-378-5408
Provider Business Practice Location Address Fax Number:
404-378-5400
Provider Enumeration Date:
09/12/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SHAH
Authorized Official First Name:
SAMIR
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
706-825-8182

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: PHRE003374 , 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: 2012320 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 00031523A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".