Provider Demographics
NPI:1245375070
Name:PROFESSIONAL MEDICAL PHARMACY
Entity type:Organization
Organization Name:PROFESSIONAL MEDICAL PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:PERNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-299-7372
Mailing Address - Street 1:4859C MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30083-4175
Mailing Address - Country:US
Mailing Address - Phone:404-299-7372
Mailing Address - Fax:404-508-9225
Practice Address - Street 1:4859C MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-4175
Practice Address - Country:US
Practice Address - Phone:404-299-7372
Practice Address - Fax:404-508-9225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH017641183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00814888AMedicaid
GA00814888BMedicaid
GA=========OtherWELLCARE
GA0854300001Medicare ID - Type UnspecifiedPHARMACY