Provider Demographics
NPI:1831476316
Name:OLDE TIME PHARMACY AT SIXES, LLC
Entity Type:Organization
Organization Name:OLDE TIME PHARMACY AT SIXES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:SUTHERLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-445-4486
Mailing Address - Street 1:684 SIXES RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:HOLLY SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30115-8721
Mailing Address - Country:US
Mailing Address - Phone:678-445-4486
Mailing Address - Fax:678-445-3536
Practice Address - Street 1:684 SIXES RD
Practice Address - Street 2:SUITE 105
Practice Address - City:HOLLY SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30115-8721
Practice Address - Country:US
Practice Address - Phone:678-445-4486
Practice Address - Fax:678-445-3536
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-10
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE009711261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center