Provider Demographics
NPI:1245675073
Name:UNADILLA DRUG COMPANY INC
Entity type:Organization
Organization Name:UNADILLA DRUG COMPANY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DHARA
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-627-3041
Mailing Address - Street 1:PO BOX 14
Mailing Address - Street 2:
Mailing Address - City:UNADILLA
Mailing Address - State:GA
Mailing Address - Zip Code:31091-0014
Mailing Address - Country:US
Mailing Address - Phone:478-627-3041
Mailing Address - Fax:478-627-3874
Practice Address - Street 1:413 SECOND ST
Practice Address - Street 2:
Practice Address - City:UNADILLA
Practice Address - State:GA
Practice Address - Zip Code:31091
Practice Address - Country:US
Practice Address - Phone:478-627-3041
Practice Address - Fax:478-627-3874
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-07
Last Update Date:2016-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0002X, 3336L0003X
GAPHRE0099213336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003136637AMedicaid
2140330OtherPK