Provider Demographics
NPI:1134853336
Name:PHARMACY ON MAIN LLC
Entity type:Organization
Organization Name:PHARMACY ON MAIN LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:JANA
Authorized Official - Middle Name:
Authorized Official - Last Name:PATTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-592-5777
Mailing Address - Street 1:120 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SYLVESTER
Mailing Address - State:GA
Mailing Address - Zip Code:31791-2192
Mailing Address - Country:US
Mailing Address - Phone:229-463-7064
Mailing Address - Fax:229-463-7034
Practice Address - Street 1:120 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SYLVESTER
Practice Address - State:GA
Practice Address - Zip Code:31791-2192
Practice Address - Country:US
Practice Address - Phone:229-463-7064
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-13
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy