Provider Demographics
NPI:1801951272
Name:KIMPAM, INC. DBA. THE MEDICINE SHOPPE
Entity type:Organization
Organization Name:KIMPAM, INC. DBA. THE MEDICINE SHOPPE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:HAROLD
Authorized Official - Last Name:MCCLANAHAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:RPH
Authorized Official - Phone:770-787-5698
Mailing Address - Street 1:2155 PACE ST
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30014-6652
Mailing Address - Country:US
Mailing Address - Phone:770-787-5698
Mailing Address - Fax:770-786-3590
Practice Address - Street 1:2155 PACE ST
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30014-6652
Practice Address - Country:US
Practice Address - Phone:770-787-5698
Practice Address - Fax:770-786-3590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH011326183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00363415AMedicaid