Provider Demographics
NPI:1164859245
Name:PRIME RX PHARMACY, INC
Entity Type:Organization
Organization Name:PRIME RX PHARMACY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHNSON
Authorized Official - Middle Name:SORTI
Authorized Official - Last Name:BESONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-358-0620
Mailing Address - Street 1:1500 MOUNT ZION RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:MORROW
Mailing Address - State:GA
Mailing Address - Zip Code:30260-4155
Mailing Address - Country:US
Mailing Address - Phone:770-968-3444
Mailing Address - Fax:770-968-3666
Practice Address - Street 1:1500 MOUNT ZION RD
Practice Address - Street 2:SUITE 104
Practice Address - City:MORROW
Practice Address - State:GA
Practice Address - Zip Code:30260-4155
Practice Address - Country:US
Practice Address - Phone:770-968-3444
Practice Address - Fax:770-968-3666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-03
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0099633336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy