Healthcare Provider Details

I. General information

NPI: 1821131996
Provider Name (Legal Business Name): CHICKAMAUGA DRUG STORE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 08/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 COVE RD
CHICKAMAUGA GA
30707-1407
US

IV. Provider business mailing address

114 COVE RD
CHICKAMAUGA GA
30707-1407
US

V. Phone/Fax

Practice location:
  • Phone: 706-375-2611
  • Fax: 706-375-6219
Mailing address:
  • Phone: 706-375-2611
  • Fax: 706-375-6219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHRE005365
License Number StateGA

VIII. Authorized Official

Name: PHILLIP TALLEY
Title or Position: CHIEF MANAGER
Credential:
Phone: 706-375-2611