Provider Demographics
NPI:1942798012
Name:WEAVERS ROCKY FACE PHARMACY GROUP INC
Entity Type:Organization
Organization Name:WEAVERS ROCKY FACE PHARMACY GROUP INC
Other - Org Name:WEAVERS ROCKY FACE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:P
Authorized Official - Last Name:BRYANT
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:706-260-7998
Mailing Address - Street 1:630 TI PI LN
Mailing Address - Street 2:
Mailing Address - City:CHATSWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30705-7786
Mailing Address - Country:US
Mailing Address - Phone:706-259-0668
Mailing Address - Fax:706-971-3893
Practice Address - Street 1:2600 OLD CHATTANOOGA RD
Practice Address - Street 2:
Practice Address - City:ROCKY FACE
Practice Address - State:GA
Practice Address - Zip Code:30740-8511
Practice Address - Country:US
Practice Address - Phone:706-259-0668
Practice Address - Fax:706-259-1890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-24
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0106223336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA411968250AMedicaid