Provider Demographics
NPI:1437130374
Name:CITY PHARMACY OF ZEBULON PC
Entity Type:Organization
Organization Name:CITY PHARMACY OF ZEBULON PC
Other - Org Name:CITY PHARMACY OF ZEBULON PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRES AND OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:GASKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-567-8844
Mailing Address - Street 1:PO BOX 128
Mailing Address - Street 2:
Mailing Address - City:ZEBULON
Mailing Address - State:GA
Mailing Address - Zip Code:30295-0128
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:460 THOMASTON ST
Practice Address - Street 2:
Practice Address - City:ZEBULON
Practice Address - State:GA
Practice Address - Zip Code:30295-3387
Practice Address - Country:US
Practice Address - Phone:770-567-8844
Practice Address - Fax:770-567-5222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-08
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
GAPHRE0057333336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00383325AMedicaid
1133420OtherNCPDP PROVIDER IDENTIFICATION NUMBER
5343020001Medicare NSC