{
"Npi": {
"NPI": "1629433529",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "YOUR CORNER DRUG STORE LLC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": "6",
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "104 LORRAINE FOREST CT",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "MACON",
"MailingAddressStateName": "GA",
"MailingAddressPostalCode": "31210-5316",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "478-994-1189",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "4260 LOG CABIN DR STE C",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "MACON",
"PracticeLocationAddressStateName": "GA",
"PracticeLocationAddressPostalCode": "31204-4852",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "478-254-8484",
"PracticeLocationAddressFaxNumber": "478-254-8020",
"EnumerationDate": "12/18/2015",
"LastUpdateDate": "04/19/2017",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "FRAZIER",
"AuthorizedOfficialFirstName": "MATTHEW",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "OWNER",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "PHARMD",
"AuthorizedOfficialTelephoneNumber": "478-254-8484",
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "3336C0004X",
"TaxonomyName": "Compounding Pharmacy",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "333600000X",
"TaxonomyName": "Pharmacy",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "3336C0003X",
"TaxonomyName": "Community/Retail Pharmacy",
"LicenseNumber": "PHRE010205",
"LicenseNumberStateCode": "GA",
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": null
}
}