Provider Demographics
NPI:1912073016
Name:FOOTHILLS PHARMACIES INC
Entity Type:Organization
Organization Name:FOOTHILLS PHARMACIES INC
Other - Org Name:MEDICAP PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:R
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:GOSS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:706-245-9959
Mailing Address - Street 1:100 FRANKLIN SPRINGS ST
Mailing Address - Street 2:
Mailing Address - City:ROYSTON
Mailing Address - State:GA
Mailing Address - Zip Code:30662-4134
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 FRANKLIN SPRINGS ST
Practice Address - Street 2:
Practice Address - City:ROYSTON
Practice Address - State:GA
Practice Address - Zip Code:30662-4134
Practice Address - Country:US
Practice Address - Phone:706-245-9959
Practice Address - Fax:706-245-9555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA8513333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000914713BMedicaid
GA00914713AMedicaid
1148786OtherOTHER ID NUMBER-COMMERCIAL NUMBER
1148786OtherOTHER ID NUMBER-COMMERCIAL NUMBER
GABM7348116OtherDEA #
GA000914713BMedicaid