Provider Demographics
NPI:1114430493
Name:EXCELSIOR SPECIALTY PHARMACY INC
Entity Type:Organization
Organization Name:EXCELSIOR SPECIALTY PHARMACY INC
Other - Org Name:EXCELSIOR SPECIALTY PHARMACY INC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/PIC/AO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:KITSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-428-7325
Mailing Address - Street 1:3652 CHAMBLEE DUNWOODY RD STE 3
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30341-2120
Mailing Address - Country:US
Mailing Address - Phone:470-222-8320
Mailing Address - Fax:470-222-8229
Practice Address - Street 1:3652 CHAMBLEE DUNWOODY RD STE 3
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30341-2120
Practice Address - Country:US
Practice Address - Phone:470-222-8320
Practice Address - Fax:470-222-8229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-09
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
GAPHRE0104043336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2173269OtherPK
GA003198495AMedicaid