Provider Demographics
NPI:1598858508
Name:CLB PHARMACY GROUP LLC
Entity Type:Organization
Organization Name:CLB PHARMACY GROUP LLC
Other - Org Name:FRIENDLY CITY PHARMACY ON 2ND
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LUCAS
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-563-6689
Mailing Address - Street 1:717 2ND ST W
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-4201
Mailing Address - Country:US
Mailing Address - Phone:229-382-3711
Mailing Address - Fax:229-387-7521
Practice Address - Street 1:717 2ND ST W
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-4201
Practice Address - Country:US
Practice Address - Phone:229-382-3711
Practice Address - Fax:229-387-7521
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0003X, 3336C0004X
GAPHRE0033943336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2012857OtherPK
GA00033855AMedicaid
GA00033855BMedicaid
GA00033855AMedicaid