Provider Demographics
NPI:1831360874
Name:TARRYTOWN EXPOCARE GA, INC.
Entity type:Organization
Organization Name:TARRYTOWN EXPOCARE GA, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:LASHLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:855-617-7312
Mailing Address - Street 1:8500 SHOAL CREEK BLVD BLDG 1
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78757-6888
Mailing Address - Country:US
Mailing Address - Phone:512-617-7312
Mailing Address - Fax:512-617-7313
Practice Address - Street 1:953 BRANCH CT
Practice Address - Street 2:
Practice Address - City:GROVETOWN
Practice Address - State:GA
Practice Address - Zip Code:30813-3325
Practice Address - Country:US
Practice Address - Phone:706-595-4840
Practice Address - Fax:706-595-8665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-18
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
GAPHRE0094613336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2016907OtherPK