Provider Demographics
NPI:1952661399
Name:VILLAGE APOTHECARY LLC
Entity Type:Organization
Organization Name:VILLAGE APOTHECARY LLC
Other - Org Name:THE VILLAGE APOTHECARY, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-327-4242
Mailing Address - Street 1:6801 RIVER RD STE 201
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-3300
Mailing Address - Country:US
Mailing Address - Phone:706-327-4242
Mailing Address - Fax:706-327-4296
Practice Address - Street 1:6801 RIVER RD BLDG 2
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-3352
Practice Address - Country:US
Practice Address - Phone:706-327-4242
Practice Address - Fax:706-327-4296
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-18
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
GAPHRE0098353336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2135341OtherPK
GA003126116AMedicaid