1205855129 NPI number — CORLEY & MCCLENDON, INC

Table of content: (NPI 1205855129)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205855129 NPI number — CORLEY & MCCLENDON, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CORLEY & MCCLENDON, 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:
CORLEY DRUGS #3
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:
1205855129
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/29/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18 NEW AIRPORT ROAD
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
LAGRANGE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30240
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-885-9213
Provider Business Mailing Address Fax Number:
706-885-9829

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
820 NORTH GREENWOOD STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAGRANGE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30240
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-882-4960
Provider Business Practice Location Address Fax Number:
706-882-1149
Provider Enumeration Date:
07/19/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
COCHRAN
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
DAVID
Authorized Official Title or Position:
OWNER/PHARMACIST
Authorized Official Telephone Number:
706-884-2661

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  PHRE006331 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1128479 . This is a "OTHER ID NUMBER-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 00290364A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1205855129 . This is a "NPI" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".