Provider Demographics
NPI:1972539443
Name:EAGLE PHARMACY,INC
Entity Type:Organization
Organization Name:EAGLE PHARMACY,INC
Other - Org Name:EAGLE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER AND PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:DELAY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:478-982-7979
Mailing Address - Street 1:936 E WINTHROPE AVE
Mailing Address - Street 2:
Mailing Address - City:MILLEN
Mailing Address - State:GA
Mailing Address - Zip Code:30442-1840
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:936 E WINTHROPE AVE
Practice Address - Street 2:
Practice Address - City:MILLEN
Practice Address - State:GA
Practice Address - Zip Code:30442-1840
Practice Address - Country:US
Practice Address - Phone:478-982-7979
Practice Address - Fax:478-982-1010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-24
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE008924333600000X
3336C0003X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1153206OtherOTHER ID NUMBER-COMMERCIAL NUMBER
GA815061467AMedicaid