Provider Demographics
NPI:1255683843
Name:BUDD TERRACE PHARMACY
Entity Type:Organization
Organization Name:BUDD TERRACE PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:HANICHEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-728-6807
Mailing Address - Street 1:1833 CLIFTON RD NE
Mailing Address - Street 2:ROOM 115
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-4021
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1833 CLIFTON RD NE
Practice Address - Street 2:ROOM 115
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-4021
Practice Address - Country:US
Practice Address - Phone:404-728-6807
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-08
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0098633336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FB3481998OtherCONTROLLED SUBSTANCE REGISTRATION CERTIFICATE
GAPHRE009863OtherGEORGIA BOARD OF PHARMACY