Provider Demographics
NPI:1609061647
Name:TALLAPOOSA DRUG COMPANY INC
Entity Type:Organization
Organization Name:TALLAPOOSA DRUG COMPANY INC
Other - Org Name:TALLAPOOSA DRUG COMPANY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER & PIC
Authorized Official - Prefix:
Authorized Official - First Name:RICKY
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:770-574-2339
Mailing Address - Street 1:24 W ALABAMA ST
Mailing Address - Street 2:
Mailing Address - City:TALLAPOOSA
Mailing Address - State:GA
Mailing Address - Zip Code:30176-1464
Mailing Address - Country:US
Mailing Address - Phone:770-574-2339
Mailing Address - Fax:770-574-7307
Practice Address - Street 1:24 W ALABAMA ST
Practice Address - Street 2:
Practice Address - City:TALLAPOOSA
Practice Address - State:GA
Practice Address - Zip Code:30176-1464
Practice Address - Country:US
Practice Address - Phone:770-574-2339
Practice Address - Fax:770-574-7307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-12
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0047963336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL100100041Medicaid
2014456OtherPK
GA00087997AMedicaid