Provider Demographics
NPI:1174852966
Name:OLD NORCROSS ROAD PHARMACY LLC
Entity Type:Organization
Organization Name:OLD NORCROSS ROAD PHARMACY LLC
Other - Org Name:OLD NORCROSS ROAD PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR/ OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LINUS
Authorized Official - Middle Name:
Authorized Official - Last Name:IGBOKWE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-682-8622
Mailing Address - Street 1:558 OLD NORCROSS RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-4385
Mailing Address - Country:US
Mailing Address - Phone:770-682-8622
Mailing Address - Fax:770-682-8623
Practice Address - Street 1:558 OLD NORCROSS RD
Practice Address - Street 2:SUITE 201
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-4385
Practice Address - Country:US
Practice Address - Phone:770-682-8622
Practice Address - Fax:770-682-8623
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-08
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0096213336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1159424OtherNCPDP PROVIDER IDENTIFICATION NUMBER