Provider Demographics
NPI:1558875294
Name:COWAN PHARMACY LLC
Entity Type:Organization
Organization Name:COWAN PHARMACY LLC
Other - Org Name:CONYERS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:FAIRCHILD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-929-1414
Mailing Address - Street 1:1179 WEST AVE SW
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30012-5280
Mailing Address - Country:US
Mailing Address - Phone:770-929-1414
Mailing Address - Fax:
Practice Address - Street 1:1179 WEST AVE SW
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012-5280
Practice Address - Country:US
Practice Address - Phone:770-929-1414
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-16
Last Update Date:2017-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0104003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy