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General NPI Number Information
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NPI Number | 1083722151
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Entity Type | Organization
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Legal Business Name | OLD ROSWELL HOLDINGS LLC
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Dates
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Enumeration Date | 08/28/2006
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Last Update Date | 04/29/2025
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Provider Practice Location Address
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Address Line | 1179 VESTAL AVE STE. 1
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City | BINGHAMTON
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State | NY
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Zip | 13903-1606
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Country | US
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Telephone | 607-723-7585
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Fax | 607-773-0936
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Provider Business Mailing Address
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Address Line | 5064 ROSWELL RD STE A200
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City | ATLANTA
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State | GA
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Zip | 30342-2252
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Country | US
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Telephone | 404-459-8005
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Fax | 404-256-5517
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Authorized Official
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Title or Position | MANAGER
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Name | TRACY EDEN
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Credential |
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Telephone | 404-459-8005
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number | 024755
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number |
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License Number State | NY
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