Healthcare Provider Details

I. General information

NPI: 1679195606
Provider Name (Legal Business Name): TMC VILLA RICA HOSPITAL, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2020
Last Update Date: 09/08/2020
Certification Date: 09/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

157 CLINIC AVE STE 202, ROOM 219
CARROLLTON GA
30117-4454
US

IV. Provider business mailing address

100 PROFESSIONAL PL STE 305
CARROLLTON GA
30117-3872
US

V. Phone/Fax

Practice location:
  • Phone: 770-812-1919
  • Fax:
Mailing address:
  • Phone: 770-812-8614
  • Fax: 770-812-8372

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: CAROL S. CREWS
Title or Position: CFO
Credential: CFO
Phone: 770-812-9745