Provider Demographics
NPI:1013465236
Name:PREMIER SPECIALTY PHARMACY LLC
Entity Type:Organization
Organization Name:PREMIER SPECIALTY PHARMACY LLC
Other - Org Name:PREMIER SPECIALTY PHARMACY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:BUFFY
Authorized Official - Middle Name:
Authorized Official - Last Name:GOUGELMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-622-8901
Mailing Address - Street 1:335 LUM CROWE RD
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-6879
Mailing Address - Country:US
Mailing Address - Phone:678-478-8019
Mailing Address - Fax:
Practice Address - Street 1:11720 MEDLOCK BRIDGE RD STE 162
Practice Address - Street 2:
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30097-1513
Practice Address - Country:US
Practice Address - Phone:770-622-8901
Practice Address - Fax:770-622-8900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-16
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
GAPHRE0103133336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2166839OtherPK