Provider Demographics
NPI:1497262778
Name:CHAMPIONS PHARMACY
Entity Type:Organization
Organization Name:CHAMPIONS PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SEPEDA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-394-4406
Mailing Address - Street 1:3886 PRINCETON LAKES WAY SW STE 180
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30331-5511
Mailing Address - Country:US
Mailing Address - Phone:470-355-7904
Mailing Address - Fax:
Practice Address - Street 1:3886 PRINCETON LAKES WAY SUITE 180
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331
Practice Address - Country:US
Practice Address - Phone:470-355-7904
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-08
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0104213336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy