Provider Demographics
NPI:1679811731
Name:ADVANCED MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:ADVANCED MEDICAL GROUP, LLC
Other - Org Name:THOMAS DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:VANCE
Authorized Official - Middle Name:T
Authorized Official - Last Name:WALL
Authorized Official - Suffix:SR
Authorized Official - Credentials:RPH
Authorized Official - Phone:877-645-3506
Mailing Address - Street 1:450 OLD PEACHTREE RD NW
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-7289
Mailing Address - Country:US
Mailing Address - Phone:877-645-3506
Mailing Address - Fax:678-689-1459
Practice Address - Street 1:118 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:GA
Practice Address - Zip Code:31626-2257
Practice Address - Country:US
Practice Address - Phone:229-498-1018
Practice Address - Fax:229-498-1012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-24
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE009897333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPHRE009897OtherRETAIL PHARMACY PERMIT