Provider Demographics
NPI:1689029951
Name:BAZE PHARMACY LLC
Entity Type:Organization
Organization Name:BAZE PHARMACY LLC
Other - Org Name:BAZE SPECIALTY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ATHELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:EZE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-323-5033
Mailing Address - Street 1:900 STARK RD
Mailing Address - Street 2:
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39759-3613
Mailing Address - Country:US
Mailing Address - Phone:662-323-5579
Mailing Address - Fax:662-323-5053
Practice Address - Street 1:1526 E FORREST AVE STE 102
Practice Address - Street 2:
Practice Address - City:EAST POINT
Practice Address - State:GA
Practice Address - Zip Code:30344-6979
Practice Address - Country:US
Practice Address - Phone:404-761-4448
Practice Address - Fax:404-761-7905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-25
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336S0011X
GAPHRE0102853336C0003X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003177187AMedicaid
2158297OtherPK
GA003175529AMedicaid
2158297OtherPK
GA003175529AMedicaid