Provider Demographics
NPI:1033598198
Name:BENZER PHARMACY GA1 LLC
Entity Type:Organization
Organization Name:BENZER PHARMACY GA1 LLC
Other - Org Name:THE PHARMACY AT LAKE OCONEE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:STINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-521-3820
Mailing Address - Street 1:1031 VILLAGE PARK DR STE 104
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30642-3755
Mailing Address - Country:US
Mailing Address - Phone:706-999-9792
Mailing Address - Fax:706-999-9795
Practice Address - Street 1:1031 VILLAGE PARK DR STE 104
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:GA
Practice Address - Zip Code:30642-3755
Practice Address - Country:US
Practice Address - Phone:706-999-9792
Practice Address - Fax:706-999-9795
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-22
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336S0011X
GAPHRE0103423336C0003X
GAPHRE0101493336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2165802OtherPK
2152101OtherPK