Provider Demographics
NPI:1184175523
Name:ICP HOLDINGS, LLC
Entity type:Organization
Organization Name:ICP HOLDINGS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:CASEY
Authorized Official - Middle Name:
Authorized Official - Last Name:GAETANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-814-1610
Mailing Address - Street 1:8601 DUNWOODY PL STE 750
Mailing Address - Street 2:
Mailing Address - City:SANDY SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30350-2519
Mailing Address - Country:US
Mailing Address - Phone:404-815-1610
Mailing Address - Fax:404-815-1609
Practice Address - Street 1:8601 DUNWOODY PL STE 750
Practice Address - Street 2:
Practice Address - City:SANDY SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30350-2519
Practice Address - Country:US
Practice Address - Phone:404-815-1610
Practice Address - Fax:404-815-1609
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-20
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2165814OtherPK