Provider Demographics
NPI:1033160668
Name:CLARKESVILLE DRUG INC
Entity Type:Organization
Organization Name:CLARKESVILLE DRUG INC
Other - Org Name:CLARKESVILLE DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER AND CHIEF PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:LEDBETTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-754-3763
Mailing Address - Street 1:PO BOX 1659
Mailing Address - Street 2:
Mailing Address - City:CLARKESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30523-0028
Mailing Address - Country:US
Mailing Address - Phone:706-754-3763
Mailing Address - Fax:706-839-1293
Practice Address - Street 1:596 W LOUISE ST
Practice Address - Street 2:STE D
Practice Address - City:CLARKESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30523-5849
Practice Address - Country:US
Practice Address - Phone:706-754-3763
Practice Address - Fax:706-839-1293
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
GAPHRE0070293336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2015959OtherPK
GA00385371BMedicaid
GA00385371AMedicaid
GA00385371AMedicaid