Provider Demographics
NPI:1396852935
Name:LIVING WELL PHARMACY #2 INC
Entity Type:Organization
Organization Name:LIVING WELL PHARMACY #2 INC
Other - Org Name:LIVING WELL EXPRESS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:PHILLIP
Authorized Official - Last Name:BRYANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-422-9355
Mailing Address - Street 1:824 GI MADDOX PKWY
Mailing Address - Street 2:SUITE B
Mailing Address - City:CHATSWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30705-2073
Mailing Address - Country:US
Mailing Address - Phone:706-517-1901
Mailing Address - Fax:706-517-2541
Practice Address - Street 1:824 GI MADDOX PKWY
Practice Address - Street 2:SUITE B
Practice Address - City:CHATSWORTH
Practice Address - State:GA
Practice Address - Zip Code:30705-2073
Practice Address - Country:US
Practice Address - Phone:706-517-1901
Practice Address - Fax:706-517-2541
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE008958183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA411552342AMedicaid