Provider Demographics
NPI:1134564461
Name:GAYCO HEALTHCARE NORTH LLC
Entity type:Organization
Organization Name:GAYCO HEALTHCARE NORTH LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BENT
Authorized Official - Middle Name:
Authorized Official - Last Name:GAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-575-1579
Mailing Address - Street 1:507 INDUSTRIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021-1714
Mailing Address - Country:US
Mailing Address - Phone:770-495-9250
Mailing Address - Fax:855-568-9477
Practice Address - Street 1:11800 WILLS RD
Practice Address - Street 2:SUITE 150
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30009-2079
Practice Address - Country:US
Practice Address - Phone:770-495-2950
Practice Address - Fax:855-568-9477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-30
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336I0012X, 3336I0012X, 3336M0002X, 3336M0003X
GAPHRE0101933336L0003X, 3336L0003X
GAPHRE0099303336L0003X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
No3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003136467AMedicaid
2154669OtherPK