Healthcare Provider Details

I. General information

NPI: 1013986744
Provider Name (Legal Business Name): AVERA DRUG CO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 MAIN ST
FORT VALLEY GA
31030-3701
US

IV. Provider business mailing address

111 MAIN ST
FORT VALLEY GA
31030-3701
US

V. Phone/Fax

Practice location:
  • Phone: 478-825-5561
  • Fax: 478-825-0934
Mailing address:
  • Phone: 478-825-5561
  • Fax: 478-825-0934

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number10944
License Number StateGA

VIII. Authorized Official

Name: MR. GARY ALTON SHEFFIELD
Title or Position: PRESIDENT
Credential: PHARMACIST
Phone: 478-825-5561