{
"Npi": {
"NPI": "1114012119",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "SUMMERVILLE PHARMACY",
"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": "2258 WRIGHTSBORO RD",
"SecondLineMailingAddress": "SUITE 150",
"MailingAddressCityName": "AUGUSTA",
"MailingAddressStateName": "GA",
"MailingAddressPostalCode": "30904",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "706-481-7140",
"MailingAddressFaxNumber": "706-733-7301",
"FirstLinePracticeLocationAddress": "3087 WESTWOOD RD",
"SecondLinePracticeLocationAddress": "HANI MUSSAD",
"PracticeLocationAddressCityName": "AUGUSTA",
"PracticeLocationAddressStateName": "GA",
"PracticeLocationAddressPostalCode": "30909",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "706-736-2093",
"PracticeLocationAddressFaxNumber": "706-733-7301",
"EnumerationDate": "10/04/2006",
"LastUpdateDate": "08/22/2020",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "MUSSAD",
"AuthorizedOfficialFirstName": "HANI",
"AuthorizedOfficialMiddleName": "WILLIAM",
"AuthorizedOfficialTitle": "OWNER/ PHARMACIST",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "BS",
"AuthorizedOfficialTelephoneNumber": "706-481-7140",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "333600000X",
"TaxonomyName": "Pharmacy",
"LicenseNumber": "RPH.004193",
"LicenseNumberStateCode": "GA",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}