Provider Demographics
NPI:1457734410
Name:NBA PHARMACY LLC
Entity Type:Organization
Organization Name:NBA PHARMACY LLC
Other - Org Name:DAWSON PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ASHISH
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-265-7193
Mailing Address - Street 1:310 PASATIEMPO LN
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-7621
Mailing Address - Country:US
Mailing Address - Phone:404-234-1800
Mailing Address - Fax:706-265-8463
Practice Address - Street 1:66 S 400 CENTER LN
Practice Address - Street 2:SUITE 125
Practice Address - City:DAWSONVILLE
Practice Address - State:GA
Practice Address - Zip Code:30534-6183
Practice Address - Country:US
Practice Address - Phone:706-265-3934
Practice Address - Fax:706-265-8463
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-08
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336S0011X
GAPHRE0101603336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003168970AMedicaid
2152987OtherPK