Provider Demographics
NPI:1831293885
Name:NAS DECATUR LLC
Entity Type:Organization
Organization Name:NAS DECATUR LLC
Other - Org Name:MCKINNEY'S APOTHECARY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMIR
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:706-825-8182
Mailing Address - Street 1:225 E PONCE DE LEON AVE
Mailing Address - Street 2:SUITE 140
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-3444
Mailing Address - Country:US
Mailing Address - Phone:404-378-5408
Mailing Address - Fax:404-378-5400
Practice Address - Street 1:225 E PONCE DE LEON AVE
Practice Address - Street 2:SUITE 140
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-3444
Practice Address - Country:US
Practice Address - Phone:404-378-5408
Practice Address - Fax:404-378-5400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
GAPHRE0033743336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2012320OtherPK
GA00031523AMedicaid