Provider Demographics
NPI:1417463738
Name:LANIER PHARMACY, LLC
Entity Type:Organization
Organization Name:LANIER PHARMACY, LLC
Other - Org Name:LANIER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:RPH/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:
Authorized Official - Last Name:CROW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-536-8861
Mailing Address - Street 1:3560 THOMPSON BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30506-1518
Mailing Address - Country:US
Mailing Address - Phone:770-536-8861
Mailing Address - Fax:770-503-1201
Practice Address - Street 1:3560 THOMPSON BRIDGE RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30506-1518
Practice Address - Country:US
Practice Address - Phone:770-536-8861
Practice Address - Fax:770-503-1201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-22
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
GAPHRE0104203336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2175196OtherPK
GA000673208AMedicaid