Provider Demographics
NPI:1770522674
Name:BARROW-STATHAM PHARMACY
Entity type:Organization
Organization Name:BARROW-STATHAM PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:TONY
Authorized Official - Middle Name:STEVE
Authorized Official - Last Name:MADDOX
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:770-725-1122
Mailing Address - Street 1:PO BOX 360
Mailing Address - Street 2:
Mailing Address - City:STATHAM
Mailing Address - State:GA
Mailing Address - Zip Code:30666-0007
Mailing Address - Country:US
Mailing Address - Phone:770-725-1122
Mailing Address - Fax:770-725-1150
Practice Address - Street 1:333 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:STATHAM
Practice Address - State:GA
Practice Address - Zip Code:30666-1710
Practice Address - Country:US
Practice Address - Phone:770-725-1122
Practice Address - Fax:770-725-1150
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA011328183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA4750300001Medicare ID - Type Unspecified