Provider Demographics
NPI:1619262433
Name:VILLA RICA RX LLC
Entity Type:Organization
Organization Name:VILLA RICA RX LLC
Other - Org Name:VILLA RICA DRUGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:COLTON
Authorized Official - Middle Name:HAROLD
Authorized Official - Last Name:BLACKMON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:770-456-4663
Mailing Address - Street 1:222 WEST WILSON STREET
Mailing Address - Street 2:
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180
Mailing Address - Country:US
Mailing Address - Phone:770-456-4663
Mailing Address - Fax:770-456-4661
Practice Address - Street 1:222 WEST WILSON STREET
Practice Address - Street 2:
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180
Practice Address - Country:US
Practice Address - Phone:770-456-4663
Practice Address - Fax:770-456-4661
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-09
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0097633336C0003X
GAPHRE0104123336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA6683090001Medicare NSC