Provider Demographics
NPI:1578648705
Name:OLDE TIME PHARMACY INC
Entity Type:Organization
Organization Name:OLDE TIME PHARMACY INC
Other - Org Name:OLDE TIME PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:NOELL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:770-313-7615
Mailing Address - Street 1:145 HIGHLANDS DR
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-6052
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:402 ARGONNE TERRACE
Practice Address - Street 2:SUITE 230
Practice Address - City:HOLLY SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30115
Practice Address - Country:US
Practice Address - Phone:770-783-0483
Practice Address - Fax:770-881-7910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
GAPHRE0090883336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1155084OtherOTHER ID NUMBER-COMMERCIAL NUMBER