Provider Demographics
NPI:1720113939
Name:MCINTYREPHARMACY LLC DBA GLENWOOD PHARMACY
Entity Type:Organization
Organization Name:MCINTYREPHARMACY LLC DBA GLENWOOD PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICKY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCINTYRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-523-5094
Mailing Address - Street 1:PO BOX 780
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30428-0780
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:114 E 2ND AVE
Practice Address - Street 2:
Practice Address - City:GLENWOOD
Practice Address - State:GA
Practice Address - Zip Code:30428
Practice Address - Country:US
Practice Address - Phone:912-523-5094
Practice Address - Fax:912-523-5137
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0080523336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000815712AMedicaid
GA5938460001Medicare NSC