Provider Demographics
NPI:1457427791
Name:LELAND PHARMACY INC
Entity Type:Organization
Organization Name:LELAND PHARMACY INC
Other - Org Name:MABLETON PHARMACY & UNIFORMS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY/TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:PAMALA
Authorized Official - Middle Name:SMITH
Authorized Official - Last Name:MARQUESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-948-3133
Mailing Address - Street 1:5390 FLOYD RD SW
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-2216
Mailing Address - Country:US
Mailing Address - Phone:770-948-3133
Mailing Address - Fax:770-948-3660
Practice Address - Street 1:5390 FLOYD RD SW
Practice Address - Street 2:
Practice Address - City:MABLETON
Practice Address - State:GA
Practice Address - Zip Code:30126-2216
Practice Address - Country:US
Practice Address - Phone:770-948-3133
Practice Address - Fax:770-948-3660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2013-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0059333336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2139728OtherPK
GA00181816AMedicaid
GA00181816AMedicaid