Provider Demographics
NPI:1003202342
Name:FLINT RIVER PHARMACY LLC
Entity Type:Organization
Organization Name:FLINT RIVER PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:TIMOTHY
Authorized Official - Last Name:HALL
Authorized Official - Suffix:JR
Authorized Official - Credentials:PHARMMD
Authorized Official - Phone:478-472-0111
Mailing Address - Street 1:506-C SPAULDING ROAD
Mailing Address - Street 2:
Mailing Address - City:MONTEZUMA
Mailing Address - State:GA
Mailing Address - Zip Code:31063-1804
Mailing Address - Country:US
Mailing Address - Phone:478-472-0111
Mailing Address - Fax:478-472-0112
Practice Address - Street 1:506-C SPAULDING ROAD
Practice Address - Street 2:
Practice Address - City:MONTEZUMA
Practice Address - State:GA
Practice Address - Zip Code:31063-1804
Practice Address - Country:US
Practice Address - Phone:478-472-0111
Practice Address - Fax:478-472-0112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-14
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE010139333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy