=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134563406
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LILBURN COMMUNITY PHARMACY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/17/2013
-----------------------------------------------------
Last Update Date | 05/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4025 LAWRENCEVILLE HWY NW STE D
-----------------------------------------------------
City | LILBURN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30047-2876
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-710-0478
-----------------------------------------------------
Fax | 770-710-0861
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2147 WHITESTONE CT SE
-----------------------------------------------------
City | SMYRNA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30080-3116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-909-8052
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ORGANIZER
-----------------------------------------------------
Name | SAMINA C KHATRI
-----------------------------------------------------
Credential | PHARMACY
-----------------------------------------------------
Telephone | 770-710-0478
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0004X
-----------------------------------------------------
Taxonomy Name | Compounding Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336S0011X
-----------------------------------------------------
Taxonomy Name | Specialty Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PHRE009917
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------