Provider Demographics
NPI:1609353945
Name:FORT VALLEY DRUG COMPANY LLC.
Entity Type:Organization
Organization Name:FORT VALLEY DRUG COMPANY LLC.
Other - Org Name:FIVE POINTS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:TIMOTHY
Authorized Official - Last Name:HALL
Authorized Official - Suffix:JR
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:478-822-0555
Mailing Address - Street 1:115 COMMERCIAL HTS
Mailing Address - Street 2:
Mailing Address - City:FORT VALLEY
Mailing Address - State:GA
Mailing Address - Zip Code:31030-3361
Mailing Address - Country:US
Mailing Address - Phone:478-822-0555
Mailing Address - Fax:478-822-0558
Practice Address - Street 1:115 COMMERCIAL HTS
Practice Address - Street 2:
Practice Address - City:FORT VALLEY
Practice Address - State:GA
Practice Address - Zip Code:31030-3361
Practice Address - Country:US
Practice Address - Phone:478-822-0555
Practice Address - Fax:478-822-0558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-19
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0106413336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPHRE010641OtherSTATE BOARD OF PHARMACY LICENSE