Healthcare Provider Details

I. General information

NPI: 1780680652
Provider Name (Legal Business Name): NURSING HOME PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2005
Last Update Date: 08/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1865 BOLD SPRINGS RD NW
MONROE GA
30656-4605
US

IV. Provider business mailing address

1865 BOLD SPRINGS RD NW
MONROE GA
30656-4605
US

V. Phone/Fax

Practice location:
  • Phone: 770-267-8677
  • Fax: 770-267-6462
Mailing address:
  • Phone: 770-267-8677
  • Fax: 770-267-6462

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License NumberPHRE004071
License Number StateGA

VIII. Authorized Official

Name: JOHN GLEATON
Title or Position: PARTNER
Credential: BS PHARMACY
Phone: 770-267-8677