Provider Demographics
NPI:1710548664
Name:GAINESVILLE PHARMACY LLC
Entity Type:Organization
Organization Name:GAINESVILLE PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ITZELIS
Authorized Official - Middle Name:
Authorized Official - Last Name:GODREAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-332-2794
Mailing Address - Street 1:3651 PEACHTREE PARKWAY SUITE E#422
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024
Mailing Address - Country:US
Mailing Address - Phone:404-884-4588
Mailing Address - Fax:678-971-1031
Practice Address - Street 1:1079 JESSE JEWELL PKWY SW
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-6103
Practice Address - Country:US
Practice Address - Phone:678-971-1000
Practice Address - Fax:678-971-1031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-21
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy