Healthcare Provider Details

I. General information

NPI: 1306105325
Provider Name (Legal Business Name): MARKETPLACE PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2012
Last Update Date: 01/28/2022
Certification Date: 01/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9205 LAVONIA RD
CARNESVILLE GA
30521-3203
US

IV. Provider business mailing address

PO BOX 355 9205 LAVONIA RD.
CARNESVILLE GA
30521
US

V. Phone/Fax

Practice location:
  • Phone: 706-384-3995
  • Fax:
Mailing address:
  • Phone: 706-384-2085
  • Fax: 706-384-2225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPHRE010393
License Number StateGA

VIII. Authorized Official

Name: MICHAEL GONZALEZ
Title or Position: PHARMACIST IN CHARGE
Credential: RPH.
Phone: 706-384-2085