=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124723101
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SKYLINE RX INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2023
-----------------------------------------------------
Last Update Date | 04/10/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4300 PLEASANT HILL RD STE F
-----------------------------------------------------
City | DULUTH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30096-6379
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-709-0900
-----------------------------------------------------
Fax | 470-709-0901
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4300 PLEASANT HILL RD STE F
-----------------------------------------------------
City | DULUTH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30096-6379
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-709-0900
-----------------------------------------------------
Fax | 470-709-0901
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | NINA LE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 470-709-0900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------