1962556225 NPI number — SMITH & STEWART DRUG

Table of content: (NPI 1962556225)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962556225 NPI number — SMITH & STEWART DRUG

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SMITH & STEWART DRUG
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:
6
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:
1962556225
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
102 N SAGE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TOCCOA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30577-3678
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-886-3141
Provider Business Mailing Address Fax Number:
706-886-4000

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
102 SAGE ST N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TOCCOA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30577-2336
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-886-3141
Provider Business Practice Location Address Fax Number:
706-886-4000
Provider Enumeration Date:
01/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DALTON
Authorized Official First Name:
JEFF
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER AND PRESIDENT OF CORPORATION
Authorized Official Telephone Number:
706-886-3141

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  PHRE006339 , 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: 1115054 . This is a "NABP #" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: GA6339 . This is a "STATE PHARMACY LICENSE #" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 000191023A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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