Healthcare Provider Details

I. General information

NPI: 1730695040
Provider Name (Legal Business Name): ELBEN RX INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2017
Last Update Date: 09/19/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

631 BROAD ST SE
GAINESVILLE GA
30501-3729
US

IV. Provider business mailing address

631 BROAD ST SE
GAINESVILLE GA
30501-3729
US

V. Phone/Fax

Practice location:
  • Phone: 770-532-0186
  • Fax: 770-503-1016
Mailing address:
  • Phone: 770-532-0186
  • Fax: 770-503-1016

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHRE010419
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: CHRISTOPHER SULLENS
Title or Position: PRESIDENT
Credential:
Phone: 770-532-0186