Provider Demographics
NPI:1417081001
Name:EAGLE'S LANDING PHARMACY
Entity Type:Organization
Organization Name:EAGLE'S LANDING PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:RINK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:770-474-5005
Mailing Address - Street 1:1090 EAGLES LANDING PKWY
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-5012
Mailing Address - Country:US
Mailing Address - Phone:770-474-5005
Mailing Address - Fax:770-474-8093
Practice Address - Street 1:1090 EAGLES LANDING PKWY
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-5012
Practice Address - Country:US
Practice Address - Phone:770-474-5005
Practice Address - Fax:770-474-8093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE007404332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0458010001Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER