Provider Demographics
NPI:1255471173
Name:MARTINEZ APOTHECARY
Entity Type:Organization
Organization Name:MARTINEZ APOTHECARY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NEIL
Authorized Official - Middle Name:W
Authorized Official - Last Name:GRICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-210-6654
Mailing Address - Street 1:3830 WASHINGTON RD
Mailing Address - Street 2:STE 11 A
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-5064
Mailing Address - Country:US
Mailing Address - Phone:706-210-6654
Mailing Address - Fax:706-210-8017
Practice Address - Street 1:3830 WASHINGTON RD
Practice Address - Street 2:STE 11 A
Practice Address - City:MARTINEZ
Practice Address - State:GA
Practice Address - Zip Code:30907-5064
Practice Address - Country:US
Practice Address - Phone:706-210-6654
Practice Address - Fax:706-210-8017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2009-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0087533336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA648923041AMedicaid
SCDE2387Medicaid
SCDE2387Medicaid