Provider Demographics
NPI:1396747580
Name:EAST MARIETTA DRUG CO INC
Entity type:Organization
Organization Name:EAST MARIETTA DRUG CO INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAMALA
Authorized Official - Middle Name:SMITH
Authorized Official - Last Name:MARQUESS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:770-973-7600
Mailing Address - Street 1:1480 ROSWELL RD
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-3670
Mailing Address - Country:US
Mailing Address - Phone:770-973-7600
Mailing Address - Fax:770-973-3032
Practice Address - Street 1:1480 ROSWELL RD
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-3670
Practice Address - Country:US
Practice Address - Phone:770-973-7600
Practice Address - Fax:770-973-3032
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-01
Last Update Date:2012-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0831400001332BX2000X
GA1112072333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00026342BMedicaid
GA00026342AMedicaid
GA1112072OtherNABP
GA1112072OtherNABP
GA00026342AMedicaid
GA=========OtherTAX ID NUMBER
GA0831400001Medicare NSC