Provider Demographics
NPI:1740577527
Name:SUGARLOAF PHARMACY INC
Entity Type:Organization
Organization Name:SUGARLOAF PHARMACY INC
Other - Org Name:SUGARLOAF PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KEROP
Authorized Official - Middle Name:
Authorized Official - Last Name:GOURDIKIAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:770-220-7770
Mailing Address - Street 1:4825 SUGARLOAF PKWY
Mailing Address - Street 2:SUITE B
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-8800
Mailing Address - Country:US
Mailing Address - Phone:770-220-7770
Mailing Address - Fax:770-220-7777
Practice Address - Street 1:4825 SUGARLOAF PKWY STE BC
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-8800
Practice Address - Country:US
Practice Address - Phone:770-220-7770
Practice Address - Fax:770-220-7777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-30
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0097813336C0003X
3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003116217AMedicaid
1161594OtherNCPDP PROVIDER IDENTIFICATION NUMBER