Provider Demographics
NPI:1639530868
Name:STATHAM CITY PHARMACY LLC
Entity Type:Organization
Organization Name:STATHAM CITY PHARMACY LLC
Other - Org Name:STATHAM CITY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:FRANKEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-726-7416
Mailing Address - Street 1:333 JEFFERSON ST
Mailing Address - Street 2:PO BOX 102
Mailing Address - City:STATHAM
Mailing Address - State:GA
Mailing Address - Zip Code:30666-1710
Mailing Address - Country:US
Mailing Address - Phone:678-726-7416
Mailing Address - Fax:678-726-7541
Practice Address - Street 1:333 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:STATHAM
Practice Address - State:GA
Practice Address - Zip Code:30666
Practice Address - Country:US
Practice Address - Phone:678-726-7416
Practice Address - Fax:678-726-7541
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-16
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
GAPHRE0106393336C0003X
GAPHRE0099823336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003143308AMedicaid
GA003143308AMedicaid