Provider Demographics
NPI:1750457925
Name:CARROLLTON PHARMACY INC
Entity Type:Organization
Organization Name:CARROLLTON PHARMACY INC
Other - Org Name:CARROLLTON PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCULLOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-834-7733
Mailing Address - Street 1:105 CLINIC AVE
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-4413
Mailing Address - Country:US
Mailing Address - Phone:770-834-7733
Mailing Address - Fax:770-834-7734
Practice Address - Street 1:105 CLINIC AVE
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-4413
Practice Address - Country:US
Practice Address - Phone:770-834-7733
Practice Address - Fax:770-834-7734
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2011-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
GAPHRE0089103336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00300396AMedicaid
1129041OtherNCPDP PROVIDER IDENTIFICATION NUMBER
1129041OtherNCPDP PROVIDER IDENTIFICATION NUMBER