Healthcare Provider Details

I. General information

NPI: 1053357509
Provider Name (Legal Business Name): LONGS DRUGS OF SANDERSVILLE GEORGIA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 09/12/2025
Certification Date: 12/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2140 PEACHTREE RD NW SUITE 232
ATLANTA GA
30309-1316
US

IV. Provider business mailing address

5700 GRANITE PARKWAY SUITE 425
PLANO TX
75024-6648
US

V. Phone/Fax

Practice location:
  • Phone: 404-231-4431
  • Fax: 404-231-5677
Mailing address:
  • Phone: 469-592-2011
  • Fax: 404-231-5677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHRE009702
License Number StateGA

VIII. Authorized Official

Name: CARL CODY COLQUITT
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 469-592-2011