Provider Demographics
NPI:1679529309
Name:HINES PRESCRIPTION SHOP, INC.
Entity Type:Organization
Organization Name:HINES PRESCRIPTION SHOP, INC.
Other - Org Name:HINES PRESCRIPTION SHOP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:TYLER
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-358-2266
Mailing Address - Street 1:302 COLLEGE DR
Mailing Address - Street 2:
Mailing Address - City:BARNESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30204-1602
Mailing Address - Country:US
Mailing Address - Phone:770-358-2266
Mailing Address - Fax:770-358-4497
Practice Address - Street 1:302 COLLEGE DR
Practice Address - Street 2:
Practice Address - City:BARNESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30204-1602
Practice Address - Country:US
Practice Address - Phone:770-358-2266
Practice Address - Fax:770-358-4497
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
GAPHRE0060933336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2013044OtherPK
GA00029323AMedicaid
2013044OtherPK