Provider Demographics
NPI:1851403794
Name:DECATUR APOTHECARY
Entity Type:Organization
Organization Name:DECATUR APOTHECARY
Other - Org Name:THE MEDICINE SHOPPE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAMIRO
Authorized Official - Middle Name:
Authorized Official - Last Name:CEPERO
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:770-813-8083
Mailing Address - Street 1:3055 SAINT ANDREWS DR
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-3584
Mailing Address - Country:US
Mailing Address - Phone:770-813-8083
Mailing Address - Fax:770-813-9365
Practice Address - Street 1:3055 SAINT ANDREWS DR
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-3584
Practice Address - Country:US
Practice Address - Phone:770-813-8083
Practice Address - Fax:770-813-9365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2011-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
GA0077653336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00820168Medicaid
1128051OtherNCPDP PROVIDER IDENTIFICATION NUMBER
GA00820168Medicaid