{
"Npi": {
"NPI": "1013465236",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "PREMIER SPECIALTY PHARMACY LLC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": "6",
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "335 LUM CROWE RD",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "ROSWELL",
"MailingAddressStateName": "GA",
"MailingAddressPostalCode": "30075-6879",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "678-478-8019",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "11720 MEDLOCK BRIDGE RD STE 162",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "JOHNS CREEK",
"PracticeLocationAddressStateName": "GA",
"PracticeLocationAddressPostalCode": "30097-1513",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "770-622-8901",
"PracticeLocationAddressFaxNumber": "770-622-8900",
"EnumerationDate": "09/16/2016",
"LastUpdateDate": "02/21/2017",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "GOUGELMANN",
"AuthorizedOfficialFirstName": "BUFFY",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "PHARMACIST IN CHARGE",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "770-622-8901",
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "333600000X",
"TaxonomyName": "Pharmacy",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "3336C0004X",
"TaxonomyName": "Compounding Pharmacy",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "3336C0003X",
"TaxonomyName": "Community/Retail Pharmacy",
"LicenseNumber": "PHRE010313",
"LicenseNumberStateCode": "GA",
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": null
}
}