Provider Demographics
NPI:1417598327
Name:CONNECT CARE PHARMACY, LLC
Entity Type:Organization
Organization Name:CONNECT CARE PHARMACY, LLC
Other - Org Name:CONNECT CARE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PIC
Authorized Official - Prefix:DR
Authorized Official - First Name:GUILLIANO
Authorized Official - Middle Name:
Authorized Official - Last Name:FORTUNE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:478-654-5222
Mailing Address - Street 1:2191 GA HWY 247 CONNECTOR
Mailing Address - Street 2:
Mailing Address - City:BYRON
Mailing Address - State:GA
Mailing Address - Zip Code:31008-5531
Mailing Address - Country:US
Mailing Address - Phone:478-654-5222
Mailing Address - Fax:478-654-5209
Practice Address - Street 1:2191 HWY 247 CONNECTOR
Practice Address - Street 2:
Practice Address - City:BYRON
Practice Address - State:GA
Practice Address - Zip Code:31008-5531
Practice Address - Country:US
Practice Address - Phone:478-654-5222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-02
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPHRE010782OtherGEORGIA PHARMACY LICENSE