Healthcare Provider Details

I. General information

NPI: 1235291642
Provider Name (Legal Business Name): BRANTLEY DRUG COMPANY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 01/19/2022
Certification Date: 01/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10172 N MAIN ST
NAHUNTA GA
31553
US

IV. Provider business mailing address

PO BOX 865
NAHUNTA GA
31553-0865
US

V. Phone/Fax

Practice location:
  • Phone: 912-462-6386
  • Fax: 912-462-7657
Mailing address:
  • Phone: 912-462-6386
  • Fax: 912-462-7657

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHRE005997
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier00249312A
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer

VIII. Authorized Official

Name: MR. JAMES CAREY MARTIN III
Title or Position: OWNER
Credential:
Phone: 912-462-6386