Provider Demographics
NPI:1720037955
Name:SOUTHERN CRESCENT PHARMACY INC
Entity Type:Organization
Organization Name:SOUTHERN CRESCENT PHARMACY INC
Other - Org Name:LAMBERT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:BONNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-463-4031
Mailing Address - Street 1:PO BOX 1549
Mailing Address - Street 2:
Mailing Address - City:PALMETTO
Mailing Address - State:GA
Mailing Address - Zip Code:30268-7549
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:405 CARLTON RD
Practice Address - Street 2:
Practice Address - City:PALMETTO
Practice Address - State:GA
Practice Address - Zip Code:30268-1052
Practice Address - Country:US
Practice Address - Phone:770-463-4031
Practice Address - Fax:770-463-4946
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-06
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
GAPHRE0089803336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00247277AMedicaid
1126906OtherNCPDP PROVIDER IDENTIFICATION NUMBER