Provider Demographics
NPI:1629132113
Name:BLAKELY PHARMACY LLC
Entity Type:Organization
Organization Name:BLAKELY PHARMACY LLC
Other - Org Name:HALL DRUG CO.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:LEIGH
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-723-3441
Mailing Address - Street 1:PO BOX 909
Mailing Address - Street 2:
Mailing Address - City:BLAKELY
Mailing Address - State:GA
Mailing Address - Zip Code:39823-0909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:90 COURT SQ
Practice Address - Street 2:
Practice Address - City:BLAKELY
Practice Address - State:GA
Practice Address - Zip Code:39823-2340
Practice Address - Country:US
Practice Address - Phone:229-723-3441
Practice Address - Fax:229-723-8707
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE010001333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes333600000XSuppliersPharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
2146842OtherPK
GA000028784AMedicaid