=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578768545
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BALL GROUND PHARMACY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2007
-----------------------------------------------------
Last Update Date | 06/02/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 245 GILMER FERRY RD
-----------------------------------------------------
City | BALL GROUND
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30107-2908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-735-6161
-----------------------------------------------------
Fax | 770-735-6925
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 245 GILMER FERRY RD
-----------------------------------------------------
City | BALL GROUND
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30107-2908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-735-6161
-----------------------------------------------------
Fax | 770-735-6925
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JEFF RICHARDSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 770-735-6161
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | PHRE007345
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------