Provider Demographics
NPI:1073582920
Name:CLINIC DRUG STORE
Entity Type:Organization
Organization Name:CLINIC DRUG STORE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LEE
Authorized Official - Middle Name:FOUCHE'
Authorized Official - Last Name:PINNELL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:229-924-2783
Mailing Address - Street 1:1001 E FORSYTH ST
Mailing Address - Street 2:PO BOX 445
Mailing Address - City:AMERICUS
Mailing Address - State:GA
Mailing Address - Zip Code:31709-3721
Mailing Address - Country:US
Mailing Address - Phone:229-924-2783
Mailing Address - Fax:229-924-9220
Practice Address - Street 1:1001 E FORSYTH ST
Practice Address - Street 2:
Practice Address - City:AMERICUS
Practice Address - State:GA
Practice Address - Zip Code:31709-3721
Practice Address - Country:US
Practice Address - Phone:229-924-2783
Practice Address - Fax:229-924-9220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-14
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003303333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1104481OtherNABP/NCPDP
GA00025088AMedicaid
GA00025088AMedicaid