Provider Demographics
NPI:1932477817
Name:ARTEM PHARMACEUTICA LLC
Entity Type:Organization
Organization Name:ARTEM PHARMACEUTICA LLC
Other - Org Name:ARTEM PHARMACEUTICA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:WODI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-944-3626
Mailing Address - Street 1:595 ROSWELL ST NE
Mailing Address - Street 2:SUITE D
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-8218
Mailing Address - Country:US
Mailing Address - Phone:770-944-3626
Mailing Address - Fax:770-944-3627
Practice Address - Street 1:595 ROSWELL ST NE STE D
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-2163
Practice Address - Country:US
Practice Address - Phone:770-944-3626
Practice Address - Fax:770-944-3627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-07
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
GAPHRE0098153336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003122021AMedicaid
1162154OtherNCPDP PROVIDER IDENTIFICATION NUMBER