1578996708 NPI number — ADAIRSVILLE WORX LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578996708 NPI number — ADAIRSVILLE WORX LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADAIRSVILLE WORX 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:
ADAIRSVILLE 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:
1578996708
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/12/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6000 JOE FRANK HARRIS PKWY NW
Provider Second Line Business Mailing Address:
SUITE F
Provider Business Mailing Address City Name:
ADAIRSVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30103-2443
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-773-3521
Provider Business Mailing Address Fax Number:
770-773-9882

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6000 JOE FRANK HARRIS PKWY NW
Provider Second Line Business Practice Location Address:
SUITE F
Provider Business Practice Location Address City Name:
ADAIRSVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30103-2443
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-773-3521
Provider Business Practice Location Address Fax Number:
770-773-9882
Provider Enumeration Date:
08/12/2013

Additional Information

Authorized Official

Authorized Official Last Name:
BOHANNON
Authorized Official First Name:
GREG
Authorized Official Middle Name:
Authorized Official Title or Position:
SHAREHOLDER
Authorized Official Telephone Number:
423-396-6963

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  PHRE009948 , 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: 2141766 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 003137336A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003137915A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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