Provider Demographics
NPI:1568566511
Name:PRIDE MEDICAL INC
Entity Type:Organization
Organization Name:PRIDE MEDICAL INC
Other - Org Name:PRIDE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:NASH
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:404-355-3788
Mailing Address - Street 1:3280 HOWELL MILL RD NW
Mailing Address - Street 2:SUITE 326
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30327-4111
Mailing Address - Country:US
Mailing Address - Phone:404-355-3788
Mailing Address - Fax:678-244-2157
Practice Address - Street 1:3280 HOWELL MILL RD NW
Practice Address - Street 2:SUITE 326
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30327-4111
Practice Address - Country:US
Practice Address - Phone:404-355-3788
Practice Address - Fax:678-244-2157
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336S0011X
GAPHRE0074913336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1141136OtherNCPDP PROVIDER IDENTIFICATION NUMBER
GA759295303AMedicaid