Provider Demographics
NPI:1013080811
Name:BALL GROUND PHARMACY LLC
Entity Type:Organization
Organization Name:BALL GROUND PHARMACY LLC
Other - Org Name:BALL GROUND PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:404-272-6893
Mailing Address - Street 1:470 VALLEY ST
Mailing Address - Street 2:STE 100
Mailing Address - City:BALL GROUND
Mailing Address - State:GA
Mailing Address - Zip Code:30107-4067
Mailing Address - Country:US
Mailing Address - Phone:770-735-6161
Mailing Address - Fax:770-735-6925
Practice Address - Street 1:470 VALLEY ST
Practice Address - Street 2:STE 100
Practice Address - City:BALL GROUND
Practice Address - State:GA
Practice Address - Zip Code:30107-4067
Practice Address - Country:US
Practice Address - Phone:770-735-6161
Practice Address - Fax:770-735-6925
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2016-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
GAPHRE0073453336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000473052CMedicaid
2017773OtherPK
GA000473052CMedicaid