Provider Demographics
NPI:1821136490
Name:CARTERS DRUG STORE
Entity Type:Organization
Organization Name:CARTERS DRUG STORE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:DR
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:J
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:770-358-0444
Mailing Address - Street 1:203 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BARNESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30204-1469
Mailing Address - Country:US
Mailing Address - Phone:770-358-0444
Mailing Address - Fax:770-358-7330
Practice Address - Street 1:203 MAIN ST
Practice Address - Street 2:
Practice Address - City:BARNESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30204-1469
Practice Address - Country:US
Practice Address - Phone:770-358-0444
Practice Address - Fax:770-358-7330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE004011183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00022855AMedicaid