Provider Demographics
NPI:1730115619
Name:BRASSTOWN PROFESSIONAL PHARMACY, INC
Entity Type:Organization
Organization Name:BRASSTOWN PROFESSIONAL PHARMACY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:S
Authorized Official - Last Name:GALLOWAY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH, COF
Authorized Official - Phone:706-745-2303
Mailing Address - Street 1:23 B MURPHY HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:BLAIRSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30512
Mailing Address - Country:US
Mailing Address - Phone:706-745-2303
Mailing Address - Fax:706-745-2333
Practice Address - Street 1:23 MURPHY HWY STE B
Practice Address - Street 2:
Practice Address - City:BLAIRSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30512-3157
Practice Address - Country:US
Practice Address - Phone:706-745-2303
Practice Address - Fax:706-745-2333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-23
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA8635332B00000X, 3336C0003X, 3336C0004X
GAD19680332BC3200X
GAC22010335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00966996AMedicaid
GA00966996BMedicaid
NC7704128Medicaid
NC0116914Medicaid
NC0116914Medicaid