Provider Demographics
NPI:1578996708
Name:ADAIRSVILLE WORX LLC
Entity Type:Organization
Organization Name:ADAIRSVILLE WORX LLC
Other - Org Name:ADAIRSVILLE DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SHAREHOLDER
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:
Authorized Official - Last Name:BOHANNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-396-6963
Mailing Address - Street 1:6000 JOE FRANK HARRIS PKWY NW
Mailing Address - Street 2:SUITE F
Mailing Address - City:ADAIRSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30103-2443
Mailing Address - Country:US
Mailing Address - Phone:770-773-3521
Mailing Address - Fax:770-773-9882
Practice Address - Street 1:6000 JOE FRANK HARRIS PKWY NW
Practice Address - Street 2:SUITE F
Practice Address - City:ADAIRSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30103-2443
Practice Address - Country:US
Practice Address - Phone:770-773-3521
Practice Address - Fax:770-773-9882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-12
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0099483336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2141766OtherPK
GA003137336AMedicaid
GA003137915AMedicaid