Provider Demographics
NPI:1477657898
Name:LACEY DRUG CO., INC.
Entity Type:Organization
Organization Name:LACEY DRUG CO., INC.
Other - Org Name:LACEY'S MARIETTA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BRADEN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:770-974-5234
Mailing Address - Street 1:790 CHURCH ST NE
Mailing Address - Street 2:SUITE 170
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-7282
Mailing Address - Country:US
Mailing Address - Phone:770-424-3131
Mailing Address - Fax:770-424-2935
Practice Address - Street 1:790 CHURCH ST NE STE 210
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-8950
Practice Address - Country:US
Practice Address - Phone:770-424-3131
Practice Address - Fax:770-424-2935
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-08
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE007082332B00000X, 333600000X, 3336C0003X, 3336C0004X
GAPHRE00700823336H0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy