Provider Demographics
NPI:1053332015
Name:LEE GOODRUM PHARMACY INC
Entity Type:Organization
Organization Name:LEE GOODRUM PHARMACY INC
Other - Org Name:LEE GOODRUM PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODRUM
Authorized Official - Suffix:
Authorized Official - Credentials:BS PHARMACY
Authorized Official - Phone:770-253-1121
Mailing Address - Street 1:40 HOSPITAL RD
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30263-1201
Mailing Address - Country:US
Mailing Address - Phone:770-253-1121
Mailing Address - Fax:770-253-3572
Practice Address - Street 1:40 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30263-1201
Practice Address - Country:US
Practice Address - Phone:770-253-1121
Practice Address - Fax:770-253-3572
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
GAPHRE0063043336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00285051AMedicaid
2014853OtherPK
GA00285051AMedicaid