Provider Demographics
NPI:1497927321
Name:GEORGIA PHARMACY VENTURES LLC
Entity Type:Organization
Organization Name:GEORGIA PHARMACY VENTURES LLC
Other - Org Name:MAGNOLIA MANOR PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:478-783-4262
Mailing Address - Street 1:PO BOX 998
Mailing Address - Street 2:
Mailing Address - City:HAWKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31036-0998
Mailing Address - Country:US
Mailing Address - Phone:478-783-4262
Mailing Address - Fax:478-783-8970
Practice Address - Street 1:342 INDUSTRIAL BLVD
Practice Address - Street 2:STE C
Practice Address - City:HAWKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:31036-2103
Practice Address - Country:US
Practice Address - Phone:478-783-4262
Practice Address - Fax:478-783-8970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-01
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
GAPHRE0094713336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2017405OtherPK
GA6117290001Medicare NSC
GA1157331OtherNCPDP