Provider Demographics
NPI:1710392790
Name:EXPRESS PHARMACY INC
Entity Type:Organization
Organization Name:EXPRESS PHARMACY INC
Other - Org Name:EXPRESS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JO
Authorized Official - Middle Name:SEUNG
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:678-702-1263
Mailing Address - Street 1:3182 STEVE REYNOLDS BLVD STE 106
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-4505
Mailing Address - Country:US
Mailing Address - Phone:770-557-0306
Mailing Address - Fax:470-395-9398
Practice Address - Street 1:3182 STEVE REYNOLDS BLVD STE 106
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-4505
Practice Address - Country:US
Practice Address - Phone:770-557-0306
Practice Address - Fax:470-395-9398
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-27
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE010069333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003151326AMedicaid