Provider Demographics
NPI:1003391491
Name:PLATINUM PHARMACY LLC
Entity type:Organization
Organization Name:PLATINUM PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:OBICHI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-822-4505
Mailing Address - Street 1:935 LANIER AVE W STE 1008
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-7434
Mailing Address - Country:US
Mailing Address - Phone:404-902-5811
Mailing Address - Fax:678-519-3115
Practice Address - Street 1:935 LANIER AVE W STE 1008
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-7434
Practice Address - Country:US
Practice Address - Phone:404-902-5811
Practice Address - Fax:678-519-3115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-01
Last Update Date:2025-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003212737AMedicaid