Provider Demographics
NPI:1609929025
Name:GARDEN LAKES PHARMACY, INC.
Entity Type:Organization
Organization Name:GARDEN LAKES PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:L
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:706-378-7946
Mailing Address - Street 1:2022 REDMOND CIR NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-1322
Mailing Address - Country:US
Mailing Address - Phone:706-378-7945
Mailing Address - Fax:706-378-7949
Practice Address - Street 1:2022 REDMOND CIR NW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-1322
Practice Address - Country:US
Practice Address - Phone:706-378-7945
Practice Address - Fax:706-378-7949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE008455183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1148217Medicaid
GA4017930001Medicare ID - Type Unspecified