Provider Demographics
NPI:1871832592
Name:NEWNAN PHARMACY INC
Entity Type:Organization
Organization Name:NEWNAN PHARMACY INC
Other - Org Name:NEWNAN PHARMACY INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHANNES
Authorized Official - Middle Name:
Authorized Official - Last Name:SMIT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-304-1345
Mailing Address - Street 1:15 BAKER RD STE 2
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-2155
Mailing Address - Country:US
Mailing Address - Phone:770-683-6771
Mailing Address - Fax:770-683-6773
Practice Address - Street 1:15 BAKER RD STE 2
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-2155
Practice Address - Country:US
Practice Address - Phone:770-683-6771
Practice Address - Fax:770-683-6773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-01
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
GAPHRE0098983336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003136100AMedicaid
2138858OtherPK