Healthcare Provider Details

I. General information

NPI: 1578648705
Provider Name (Legal Business Name): OLDE TIME PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 ARGONNE TERRACE SUITE 230
HOLLY SPRINGS GA
30115
US

IV. Provider business mailing address

145 HIGHLANDS DR
WOODSTOCK GA
30188-6052
US

V. Phone/Fax

Practice location:
  • Phone: 770-783-0483
  • Fax: 770-881-7910
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHRE009088
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: RICHARD NOELL
Title or Position: PRESIDENT
Credential: RPH
Phone: 770-313-7615