Provider Demographics
NPI:1780792101
Name:MADISON DRUG, LLC
Entity type:Organization
Organization Name:MADISON DRUG, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:KELLI
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:BASS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:706-342-1722
Mailing Address - Street 1:P.O. BOX 1266
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:GA
Mailing Address - Zip Code:30650
Mailing Address - Country:US
Mailing Address - Phone:706-342-1722
Mailing Address - Fax:706-342-3277
Practice Address - Street 1:213 N. MAIN ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:GA
Practice Address - Zip Code:30650-1312
Practice Address - Country:US
Practice Address - Phone:706-342-1722
Practice Address - Fax:706-342-3277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-27
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0002X
GAPHRE0060203336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00031215AMedicaid
2012577OtherPK
2012577OtherPK