Provider Demographics
NPI:1619044914
Name:MIDCITY PHARMACY
Entity Type:Organization
Organization Name:MIDCITY PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:GRADY
Authorized Official - Last Name:CAGLE
Authorized Official - Suffix:JR
Authorized Official - Credentials:PHARMIST
Authorized Official - Phone:770-479-5533
Mailing Address - Street 1:196 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-2707
Mailing Address - Country:US
Mailing Address - Phone:770-479-5533
Mailing Address - Fax:770-479-5534
Practice Address - Street 1:196 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-2707
Practice Address - Country:US
Practice Address - Phone:770-479-5533
Practice Address - Fax:770-479-5534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2008-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA8181183500000X
332B00000X332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00032051BMedicaid
87BBBCSOtherMEDICARE PART B
GA00032051AMedicaid
GA1102401OtherNABP
GA87BBBCSMedicare PIN
GA00032051BMedicaid