=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104132521
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FORDS PHARMACY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2010
-----------------------------------------------------
Last Update Date | 12/31/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7441 ADAIRSVILLE HWY
-----------------------------------------------------
City | ADAIRSVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30103-2014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-773-1800
-----------------------------------------------------
Fax | 770-773-1809
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7441 ADAIRSVILLE HWY
-----------------------------------------------------
City | ADAIRSVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30103-2014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-773-1800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MARK FORD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 770-547-1465
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PHRE009680
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------