Provider Demographics
NPI:1164588224
Name:FLETCHER FAMILY PHARMACY, INC.
Entity Type:Organization
Organization Name:FLETCHER FAMILY PHARMACY, INC.
Other - Org Name:MEDICINE SHOPPE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:FLETCHER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:229-388-1666
Mailing Address - Street 1:214 18TH ST E
Mailing Address - Street 2:SUITE A
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-3512
Mailing Address - Country:US
Mailing Address - Phone:229-388-1666
Mailing Address - Fax:229-388-1391
Practice Address - Street 1:214 18TH ST E
Practice Address - Street 2:SUITE A
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-3512
Practice Address - Country:US
Practice Address - Phone:229-388-1666
Practice Address - Fax:229-388-1391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-30
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA15733183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00587397AMedicaid