Provider Demographics
NPI:1942436027
Name:PROVIDENCE PHARMACY INC
Entity Type:Organization
Organization Name:PROVIDENCE PHARMACY INC
Other - Org Name:PROVIDENCE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CLEMENT
Authorized Official - Middle Name:EMEKA
Authorized Official - Last Name:OKPALA
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:678-489-2069
Mailing Address - Street 1:180 W BROAD ST STE A
Mailing Address - Street 2:
Mailing Address - City:FAIRBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30213
Mailing Address - Country:US
Mailing Address - Phone:678-489-2069
Mailing Address - Fax:678-489-8627
Practice Address - Street 1:180 W BROAD ST STE A
Practice Address - Street 2:
Practice Address - City:FAIRBURN
Practice Address - State:GA
Practice Address - Zip Code:30213
Practice Address - Country:US
Practice Address - Phone:678-489-2069
Practice Address - Fax:678-489-8627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-03
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA054275159AMedicaid