Provider Demographics
NPI:1982687364
Name:DAHLONEGA PHARMACY INC
Entity Type:Organization
Organization Name:DAHLONEGA PHARMACY INC
Other - Org Name:DAHLONEGA PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MGR
Authorized Official - Prefix:
Authorized Official - First Name:ALLISON
Authorized Official - Middle Name:
Authorized Official - Last Name:LAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:CPTH
Authorized Official - Phone:706-864-2522
Mailing Address - Street 1:70 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:DAHLONEGA
Mailing Address - State:GA
Mailing Address - Zip Code:30533-0800
Mailing Address - Country:US
Mailing Address - Phone:706-864-2522
Mailing Address - Fax:706-864-5051
Practice Address - Street 1:70 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:DAHLONEGA
Practice Address - State:GA
Practice Address - Zip Code:30533-0800
Practice Address - Country:US
Practice Address - Phone:706-864-2522
Practice Address - Fax:706-864-5051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-21
Last Update Date:2017-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X, 3336L0003X
GAPHRE0032603336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2012188OtherPK
GA000025638BMedicaid
2012188OtherPK