Provider Demographics
NPI:1497840821
Name:CASTLEBERRY DRUG COMPANY, LLC
Entity Type:Organization
Organization Name:CASTLEBERRY DRUG COMPANY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JEP
Authorized Official - Middle Name:E
Authorized Official - Last Name:CASTLEBERRY
Authorized Official - Suffix:III
Authorized Official - Credentials:RPH
Authorized Official - Phone:478-994-2051
Mailing Address - Street 1:P.O. BOX 188
Mailing Address - Street 2:
Mailing Address - City:FORSYTH
Mailing Address - State:GA
Mailing Address - Zip Code:31029
Mailing Address - Country:US
Mailing Address - Phone:478-994-2051
Mailing Address - Fax:478-994-3014
Practice Address - Street 1:67 N. LEE ST
Practice Address - Street 2:
Practice Address - City:FORSYTH
Practice Address - State:GA
Practice Address - Zip Code:31029
Practice Address - Country:US
Practice Address - Phone:478-994-2051
Practice Address - Fax:478-994-3014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE000675183500000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00022965AMedicaid
0743010001Medicare NSC