=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215031877
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OLD ROSWELL HOLDINGS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2006
-----------------------------------------------------
Last Update Date | 04/29/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1101 PARKWAY VIEW DR
-----------------------------------------------------
City | PITTSBURGH
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15205-1425
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-697-4880
-----------------------------------------------------
Fax | 412-697-4897
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5064 ROSWELL RD STE A200
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30342-2252
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-459-8005
-----------------------------------------------------
Fax | 404-256-5517
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | TRACY EDEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 404-459-8005
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number | PP411059L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------