Provider Demographics
NPI:1336234855
Name:MONFORT DRUG COMPANY
Entity Type:Organization
Organization Name:MONFORT DRUG COMPANY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:CARTER
Authorized Official - Last Name:GORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:770-963-2438
Mailing Address - Street 1:PO BOX 821
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-0821
Mailing Address - Country:US
Mailing Address - Phone:770-963-2438
Mailing Address - Fax:770-963-0166
Practice Address - Street 1:470 NORTH CLAYTON STREET
Practice Address - Street 2:SUITE 101
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045
Practice Address - Country:US
Practice Address - Phone:770-963-2438
Practice Address - Fax:770-963-0166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA5529183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00032227AMedicaid
GA00032227AMedicaid