Healthcare Provider Details

I. General information

NPI: 1609929025
Provider Name (Legal Business Name): GARDEN LAKES PHARMACY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2022 REDMOND CIR NW
ROME GA
30165-1322
US

IV. Provider business mailing address

2022 REDMOND CIR NW
ROME GA
30165-1322
US

V. Phone/Fax

Practice location:
  • Phone: 706-378-7945
  • Fax: 706-378-7949
Mailing address:
  • Phone: 706-378-7945
  • Fax: 706-378-7949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPHRE008455
License Number StateGA

VIII. Authorized Official

Name: MR. DONALD L. HENDERSON
Title or Position: PRESIDENT
Credential: R.PH.
Phone: 706-378-7946