Healthcare Provider Details

I. General information

NPI: 1619044914
Provider Name (Legal Business Name): MIDCITY PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 07/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

196 E MAIN ST
CANTON GA
30114-2707
US

IV. Provider business mailing address

196 E MAIN ST
CANTON GA
30114-2707
US

V. Phone/Fax

Practice location:
  • Phone: 770-479-5533
  • Fax: 770-479-5534
Mailing address:
  • Phone: 770-479-5533
  • Fax: 770-479-5534

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number8181
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number332B00000X
License Number State

VIII. Authorized Official

Name: MR. WILLIAM GRADY CAGLE JR.
Title or Position: OWNER
Credential: PHARMIST
Phone: 770-479-5533