Provider Demographics
NPI:1750448874
Name:SWAN PHARMACY INC
Entity Type:Organization
Organization Name:SWAN PHARMACY INC
Other - Org Name:GUNN DRUG COMPANY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:BATTLE
Authorized Official - Last Name:SWAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:478-252-5252
Mailing Address - Street 1:48 N MAIN ST
Mailing Address - Street 2:PO BOX 69
Mailing Address - City:WADLEY
Mailing Address - State:GA
Mailing Address - Zip Code:30477-0069
Mailing Address - Country:US
Mailing Address - Phone:478-252-5252
Mailing Address - Fax:478-252-1770
Practice Address - Street 1:48 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WADLEY
Practice Address - State:GA
Practice Address - Zip Code:30477
Practice Address - Country:US
Practice Address - Phone:478-252-5252
Practice Address - Fax:478-252-1770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0001673336C0003X
GAPHRE0106343336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000028619AMedicaid
GA00028619AMedicaid