1023210044 NPI number — PEACHTREE PHARMACY SERVICES

Table of content: (NPI 1023210044)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023210044 NPI number — PEACHTREE PHARMACY SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEACHTREE PHARMACY SERVICES
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:
Provider Other Organization Name Type Code:
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:
1023210044
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/06/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1018 SOUTH MAIN STR
Provider Second Line Business Mailing Address:
HWY 129 SUITE A
Provider Business Mailing Address City Name:
CLEVELAND
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30528
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-865-0367
Provider Business Mailing Address Fax Number:
706-865-0931

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1018 SOUTH MAIN STR
Provider Second Line Business Practice Location Address:
HWY 129 SUITE A
Provider Business Practice Location Address City Name:
CLEVELAND
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30528
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-865-0367
Provider Business Practice Location Address Fax Number:
706-865-0931
Provider Enumeration Date:
06/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HERNDON
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
CHARLES
Authorized Official Title or Position:
PHARMACY MANAGER
Authorized Official Telephone Number:
706-865-0367

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  014565 , 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: PHRE009156 . This is a "PHARMACY LIC NUM" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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