Provider Demographics
NPI:1245781061
Name:BAZE SPECIALTY PHARMACY, LLC
Entity Type:Organization
Organization Name:BAZE SPECIALTY PHARMACY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:ATHELIA
Authorized Official - Middle Name:BALAMS
Authorized Official - Last Name:EZE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:662-323-5033
Mailing Address - Street 1:900 STARK RD
Mailing Address - Street 2:
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39759-3613
Mailing Address - Country:US
Mailing Address - Phone:662-323-5033
Mailing Address - Fax:662-323-5053
Practice Address - Street 1:1526 E FORREST AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:EAST POINT
Practice Address - State:GA
Practice Address - Zip Code:30344-6986
Practice Address - Country:US
Practice Address - Phone:404-761-4448
Practice Address - Fax:404-761-7905
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BAZE PHARMACY, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-17
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE010285332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies