Provider Demographics
NPI:1780738245
Name:SILVER CREEK RX LLC
Entity type:Organization
Organization Name:SILVER CREEK RX LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:PURVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-292-0106
Mailing Address - Street 1:PO BOX 230
Mailing Address - Street 2:
Mailing Address - City:SILVER CREEK
Mailing Address - State:GA
Mailing Address - Zip Code:30173-2438
Mailing Address - Country:US
Mailing Address - Phone:706-292-0106
Mailing Address - Fax:706-292-0647
Practice Address - Street 1:4450 ROCKMART RD SE
Practice Address - Street 2:
Practice Address - City:SILVER CREEK
Practice Address - State:GA
Practice Address - Zip Code:30173-2438
Practice Address - Country:US
Practice Address - Phone:706-292-0106
Practice Address - Fax:706-292-0647
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2017-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
GAPHRE0102663336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
2158643OtherPK
GA000821818AMedicaid
GA00821818AMedicaid