Provider Demographics
NPI:1821456997
Name:PROMINENCE PHARMACY PC
Entity Type:Organization
Organization Name:PROMINENCE PHARMACY PC
Other - Org Name:PROMINENCE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:YOHANNES
Authorized Official - Middle Name:
Authorized Official - Last Name:HAILE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-265-1332
Mailing Address - Street 1:131 PROMINENCE CT STE 140
Mailing Address - Street 2:
Mailing Address - City:DAWSONVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30534-8933
Mailing Address - Country:US
Mailing Address - Phone:706-265-1332
Mailing Address - Fax:706-265-1333
Practice Address - Street 1:131 PROMINENCE CT STE 140
Practice Address - Street 2:
Practice Address - City:DAWSONVILLE
Practice Address - State:GA
Practice Address - Zip Code:30534-8933
Practice Address - Country:US
Practice Address - Phone:706-265-1332
Practice Address - Fax:706-265-1333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-04
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
GAPHRE0102633336C0003X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003172822AMedicaid
2157940OtherPK