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General NPI Number Information
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NPI Number | 1619262433
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Entity Type | Organization
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Legal Business Name | VILLA RICA RX LLC
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Dates
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Enumeration Date | 06/09/2011
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Last Update Date | 06/26/2018
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Provider Practice Location Address
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Address Line | 222 WEST WILSON STREET
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City | VILLA RICA
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State | GA
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Zip | 30180
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Country | US
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Telephone | 770-456-4663
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Fax | 770-456-4661
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Provider Business Mailing Address
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Address Line | 222 WEST WILSON STREET
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City | VILLA RICA
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State | GA
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Zip | 30180
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Country | US
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Telephone | 770-456-4663
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Fax | 770-456-4661
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Authorized Official
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Title or Position | OWNER
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Name | MR. COLTON HAROLD BLACKMON
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Credential | PHARM D
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Telephone | 770-456-4663
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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 | PHRE009763
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | PHRE010412
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License Number State | GA
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