Provider Demographics
NPI:1023123825
Name:LACEY DRUG COMPANY INC
Entity type:Organization
Organization Name:LACEY DRUG COMPANY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:V-P
Authorized Official - Prefix:
Authorized Official - First Name:BENNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:FLANAGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-236-0400
Mailing Address - Street 1:4469 LEMON ST
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-5418
Mailing Address - Country:US
Mailing Address - Phone:678-236-0400
Mailing Address - Fax:678-236-0404
Practice Address - Street 1:4469 LEMON ST
Practice Address - Street 2:
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30101-5418
Practice Address - Country:US
Practice Address - Phone:678-236-0400
Practice Address - Fax:678-236-0404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
GAPHRE0089143336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA30357CMedicaid
2015785OtherPK
GA30357CMedicaid