Healthcare Provider Details

I. General information

NPI: 1831273747
Provider Name (Legal Business Name): LACEY DRUG COMPANY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 11/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4797 S MAIN ST
ACWORTH GA
30101-5339
US

IV. Provider business mailing address

4797 S MAIN ST
ACWORTH GA
30101-5339
US

V. Phone/Fax

Practice location:
  • Phone: 770-974-3131
  • Fax: 770-975-9735
Mailing address:
  • Phone: 770-974-3131
  • Fax: 770-975-9735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MS. CAROL JERAULD
Title or Position: DME MANAGER
Credential:
Phone: 770-974-3131