Healthcare Provider Details

I. General information

NPI: 1245691534
Provider Name (Legal Business Name): FAIRYLAND PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2016
Last Update Date: 03/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MCFARLAND RD
LOOKOUT MTN GA
30750-3121
US

IV. Provider business mailing address

100 MCFARLAND RD
LOOKOUT MTN GA
30750-3121
US

V. Phone/Fax

Practice location:
  • Phone: 706-820-1627
  • Fax: 706-820-1164
Mailing address:
  • Phone: 706-820-1627
  • Fax: 706-820-1164

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPHRE002347
License Number StateGA

VIII. Authorized Official

Name: MR. ALAN MITCHELL VOGES JR.
Title or Position: OWNER
Credential: RPH
Phone: 706-820-1627