Provider Demographics
NPI:1205855129
Name:CORLEY & MCCLENDON, INC
Entity Type:Organization
Organization Name:CORLEY & MCCLENDON, INC
Other - Org Name:CORLEY DRUGS #3
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:COCHRAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:706-884-2661
Mailing Address - Street 1:18 NEW AIRPORT ROAD
Mailing Address - Street 2:SUITE B
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240
Mailing Address - Country:US
Mailing Address - Phone:706-885-9213
Mailing Address - Fax:706-885-9829
Practice Address - Street 1:820 NORTH GREENWOOD STREET
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240
Practice Address - Country:US
Practice Address - Phone:706-882-4960
Practice Address - Fax:706-882-1149
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHEASTERN PHARMACEUTICALS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-19
Last Update Date:2009-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE006331333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1128479OtherOTHER ID NUMBER-COMMERCIAL NUMBER
GA00290364AMedicaid
GA1205855129OtherNPI
GA00290364AMedicaid