Healthcare Provider Details

I. General information

NPI: 1982713566
Provider Name (Legal Business Name): LACEY DRUG COMPANY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 09/10/2026
Certification Date:
Deactivation Date: 03/26/2024
Reactivation Date: 09/10/2026

III. Provider practice location address

790 CHURCH ST NE STE 210
MARIETTA GA
30060-8950
US

IV. Provider business mailing address

790 CHURCH ST NE SUITE 170
MARIETTA GA
30060-7282
US

V. Phone/Fax

Practice location:
  • Phone: 770-424-3131
  • Fax: 770-424-2935
Mailing address:
  • Phone: 770-424-3131
  • Fax: 770-424-2935

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberPHRE007082
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License NumberPHRE007082
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License NumberPHRE007082
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License NumberPHRE007082
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPHRE007082
License Number StateGA
# 6
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHRE007082
License Number StateGA
# 7
Primary TaxonomyN
Taxonomy Code3336H0001X
TaxonomyHome Infusion Therapy Pharmacy
License NumberPHRE007082
License Number StateGA
# 8
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License NumberPHRE007082
License Number StateGA
# 9
Primary TaxonomyN
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License NumberPHRE007082
License Number StateGA
# 10
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License NumberPHRE007082
License Number StateGA

VIII. Authorized Official

Name: LARRY LINDSEY BRADEN
Title or Position: MANAGER
Credential:
Phone: 770-424-3131