Provider Demographics
NPI:1417216128
Name:PROCARE PHARMACY, LLC
Entity Type:Organization
Organization Name:PROCARE PHARMACY, LLC
Other - Org Name:ENCOMPASS RX 48637
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARKOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-770-3303
Mailing Address - Street 1:1127 BRYN MAWR AVE
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374-4558
Mailing Address - Country:US
Mailing Address - Phone:909-799-4174
Mailing Address - Fax:909-799-4364
Practice Address - Street 1:2700 NORTHEAST EXPY NE
Practice Address - Street 2:SUITE B-800
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30345
Practice Address - Country:US
Practice Address - Phone:404-367-9111
Practice Address - Fax:404-367-9199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-15
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336S0011X
GAPHRE0098303336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003123975AMedicaid
SC7G9830Medicaid
2135141OtherPK
VA1417216128Medicaid
DC058513900Medicaid