Provider Demographics
NPI:1023210044
Name:PEACHTREE PHARMACY SERVICES
Entity Type:Organization
Organization Name:PEACHTREE PHARMACY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:HERNDON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:706-865-0367
Mailing Address - Street 1:1018 SOUTH MAIN STR
Mailing Address - Street 2:HWY 129 SUITE A
Mailing Address - City:CLEVELAND
Mailing Address - State:GA
Mailing Address - Zip Code:30528
Mailing Address - Country:US
Mailing Address - Phone:706-865-0367
Mailing Address - Fax:706-865-0931
Practice Address - Street 1:1018 SOUTH MAIN STR
Practice Address - Street 2:HWY 129 SUITE A
Practice Address - City:CLEVELAND
Practice Address - State:GA
Practice Address - Zip Code:30528
Practice Address - Country:US
Practice Address - Phone:706-865-0367
Practice Address - Fax:706-865-0931
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-01
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA014565183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPHRE009156OtherPHARMACY LIC NUM
GAPHRE009156OtherPHARMACY LIC NUM
5932450001Medicare Oscar/Certification
GA5932450001Medicare PIN