Provider Demographics
NPI:1982954095
Name:PEACHTREE PHARMACY & MEDICAL SUPPLY, INC.
Entity Type:Organization
Organization Name:PEACHTREE PHARMACY & MEDICAL SUPPLY, INC.
Other - Org Name:PEACHTREE PHARMACY & MEDICAL SUPPLY, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST/CCEO
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:EKWEBELEM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-488-4525
Mailing Address - Street 1:579 CONCORD RD SE STE 900
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30082-2739
Mailing Address - Country:US
Mailing Address - Phone:770-405-8664
Mailing Address - Fax:770-405-8663
Practice Address - Street 1:579 CONCORD RD SE STE 900
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30082-2739
Practice Address - Country:US
Practice Address - Phone:770-405-8664
Practice Address - Fax:770-405-8663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-17
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0098563336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1162801OtherNCPDP PROVIDER IDENTIFICATION NUMBER