Provider Demographics
NPI:1184841637
Name:MCDANIEL PHARMACY
Entity Type:Organization
Organization Name:MCDANIEL PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:TRENTON
Authorized Official - Middle Name:SAMUEL
Authorized Official - Last Name:MCDANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:478-934-6885
Mailing Address - Street 1:195 E DYKES ST
Mailing Address - Street 2:
Mailing Address - City:COCHRAN
Mailing Address - State:GA
Mailing Address - Zip Code:31014-6514
Mailing Address - Country:US
Mailing Address - Phone:478-934-6885
Mailing Address - Fax:478-934-7312
Practice Address - Street 1:195 E DYKES ST
Practice Address - Street 2:
Practice Address - City:COCHRAN
Practice Address - State:GA
Practice Address - Zip Code:31014-6514
Practice Address - Country:US
Practice Address - Phone:478-934-6885
Practice Address - Fax:478-934-7312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2014-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE006862332B00000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00356496AMedicaid
GA00356496BMedicaid
GA1055080001Medicare NSC