Provider Demographics
NPI:1831480078
Name:TOWNE LAKE FAMILY PHARMACY LLC
Entity Type:Organization
Organization Name:TOWNE LAKE FAMILY PHARMACY LLC
Other - Org Name:TOWNE LAKE FAMILY PHARMACY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OFORI
Authorized Official - Middle Name:
Authorized Official - Last Name:QUARCOO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-635-7697
Mailing Address - Street 1:2360 TOWNE LAKE PKWY STE 102
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-5576
Mailing Address - Country:US
Mailing Address - Phone:770-635-7697
Mailing Address - Fax:770-635-7526
Practice Address - Street 1:2360 TOWNE LAKE PKWY STE 102
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-5576
Practice Address - Country:US
Practice Address - Phone:770-635-7697
Practice Address - Fax:770-635-7526
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-21
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0004X
GAPHRE0097463336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003109334AMedicaid
2130061OtherPK