Provider Demographics
NPI:1912921529
Name:JM CARDINAL INVESTMENTS LLC LAWRENCEVILLE
Entity Type:Organization
Organization Name:JM CARDINAL INVESTMENTS LLC LAWRENCEVILLE
Other - Org Name:CONCORD PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIE
Authorized Official - Middle Name:D
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-463-9598
Mailing Address - Street 1:8612 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-4829
Mailing Address - Country:US
Mailing Address - Phone:678-285-0760
Mailing Address - Fax:770-971-0315
Practice Address - Street 1:575 PROFESSIONAL DR STE 170
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-3335
Practice Address - Country:US
Practice Address - Phone:770-338-0971
Practice Address - Fax:770-338-5275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0087603336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00322858JMedicaid