Provider Demographics
NPI:1346263498
Name:LITTLE CREEK DRUG LLC
Entity Type:Organization
Organization Name:LITTLE CREEK DRUG LLC
Other - Org Name:SOUTHERN DRUG CO- DARIEN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:HARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:912-294-1684
Mailing Address - Street 1:711 LAMBERT BENNETT RD
Mailing Address - Street 2:
Mailing Address - City:JESUP
Mailing Address - State:GA
Mailing Address - Zip Code:31546
Mailing Address - Country:US
Mailing Address - Phone:912-294-1684
Mailing Address - Fax:912-437-7621
Practice Address - Street 1:1001 NORTH WAY
Practice Address - Street 2:
Practice Address - City:DARIEN
Practice Address - State:GA
Practice Address - Zip Code:31305
Practice Address - Country:US
Practice Address - Phone:912-437-6353
Practice Address - Fax:912-437-7621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA8398333600000X, 3336C0003X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1147049OtherOTHER ID NUMBER-COMMERCIAL NUMBER
GA00862672AMedicaid
1147049OtherOTHER ID NUMBER-COMMERCIAL NUMBER