Healthcare Provider Details

I. General information

NPI: 1639530868
Provider Name (Legal Business Name): STATHAM CITY PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2016
Last Update Date: 10/24/2023
Certification Date: 10/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 JEFFERSON ST
STATHAM GA
30666
US

IV. Provider business mailing address

333 JEFFERSON ST PO BOX 102
STATHAM GA
30666-1710
US

V. Phone/Fax

Practice location:
  • Phone: 678-726-7416
  • Fax: 678-726-7541
Mailing address:
  • Phone: 678-726-7416
  • Fax: 678-726-7541

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHRE010639
License Number StateGA

VIII. Authorized Official

Name: MICHAEL FRANKEL
Title or Position: OWNER
Credential:
Phone: 678-726-7416