Provider Demographics
NPI:1912208539
Name:OLDE TIME PHARMACY AT SIXES LLC
Entity Type:Organization
Organization Name:OLDE TIME PHARMACY AT SIXES LLC
Other - Org Name:OLDE TIME PHARMACY AT SIXES, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
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:770-783-0483
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:770-783-0483
Mailing Address - Fax:
Practice Address - Street 1:684 SIXES RD STE 105
Practice Address - Street 2:
Practice Address - City:HOLLY SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30115-8720
Practice Address - Country:US
Practice Address - Phone:770-783-0483
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-12
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
GAPHRE0097113336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1160643OtherNCPDP PROVIDER IDENTIFICATION NUMBER