Provider Demographics
NPI:1972000917
Name:EAST MARIETTA DRUG COMPANY, INC
Entity Type:Organization
Organization Name:EAST MARIETTA DRUG COMPANY, INC
Other - Org Name:EAST MARIETTA DRUG COMPANY, INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MARQUESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-973-7600
Mailing Address - Street 1:8612 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-4829
Mailing Address - Country:US
Mailing Address - Phone:678-285-0760
Mailing Address - Fax:770-971-0315
Practice Address - Street 1:1480 ROSWELL RD
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-3670
Practice Address - Country:US
Practice Address - Phone:770-973-7600
Practice Address - Fax:770-973-3032
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-06
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
GAPHRE0078883336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000026342AMedicaid
2176495OtherPK