Provider Demographics
NPI:1356534689
Name:SWEET ONION PHARMACY
Entity type:Organization
Organization Name:SWEET ONION PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:
Authorized Official - Last Name:OLIVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-537-4747
Mailing Address - Street 1:PO BOX 872
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:GA
Mailing Address - Zip Code:30445-0872
Mailing Address - Country:US
Mailing Address - Phone:912-583-4108
Mailing Address - Fax:
Practice Address - Street 1:2321 E 1ST ST
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-8811
Practice Address - Country:US
Practice Address - Phone:912-537-4747
Practice Address - Fax:912-537-4846
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-21
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0095333336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1156024OtherNCPDP PROVIDER IDENTIFICATION NUMBER
GA834397069AMedicaid