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General NPI Number Information
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NPI Number | 1174852966
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Entity Type | Organization
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Legal Business Name | OLD NORCROSS ROAD PHARMACY LLC
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Dates
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Enumeration Date | 12/08/2009
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Last Update Date | 08/10/2010
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Provider Practice Location Address
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Address Line | 558 OLD NORCROSS RD SUITE 201
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City | LAWRENCEVILLE
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State | GA
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Zip | 30046-4385
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Country | US
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Telephone | 770-682-8622
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Fax | 770-682-8623
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Provider Business Mailing Address
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Address Line | 558 OLD NORCROSS RD SUITE 201
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City | LAWRENCEVILLE
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State | GA
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Zip | 30046-4385
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Country | US
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Telephone | 770-682-8622
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Fax | 770-682-8623
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Authorized Official
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Title or Position | DIRECTOR/ OWNER
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Name | LINUS IGBOKWE
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Credential |
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Telephone | 770-682-8622
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | PHRE009621
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License Number State | GA
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