Provider Demographics
NPI:1013986744
Name:AVERA DRUG CO
Entity Type:Organization
Organization Name:AVERA DRUG CO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:ALTON
Authorized Official - Last Name:SHEFFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:478-825-5561
Mailing Address - Street 1:111 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FORT VALLEY
Mailing Address - State:GA
Mailing Address - Zip Code:31030-3701
Mailing Address - Country:US
Mailing Address - Phone:478-825-5561
Mailing Address - Fax:478-825-0934
Practice Address - Street 1:111 MAIN ST
Practice Address - Street 2:
Practice Address - City:FORT VALLEY
Practice Address - State:GA
Practice Address - Zip Code:31030-3701
Practice Address - Country:US
Practice Address - Phone:478-825-5561
Practice Address - Fax:478-825-0934
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10944183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00021513AMedicaid
0747000001Medicare ID - Type Unspecified
GA0747000001Medicare ID - Type Unspecified