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General NPI Number Information
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NPI Number | 1740577527
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Entity Type | Organization
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Legal Business Name | SUGARLOAF PHARMACY INC
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Dates
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Enumeration Date | 06/30/2011
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Last Update Date | 02/08/2012
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Provider Practice Location Address
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Address Line | 4825 SUGARLOAF PKWY STE BC
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City | LAWRENCEVILLE
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State | GA
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Zip | 30044-8800
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Country | US
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Telephone | 770-220-7770
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Fax | 770-220-7777
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Provider Business Mailing Address
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Address Line | 4825 SUGARLOAF PKWY SUITE B
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City | LAWRENCEVILLE
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State | GA
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Zip | 30044-8800
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Country | US
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Telephone | 770-220-7770
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Fax | 770-220-7777
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Authorized Official
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Title or Position | PHARMACY DIRECTOR
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Name | KEROP GOURDIKIAN
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Credential | PHARM D
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Telephone | 770-220-7770
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0004X
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Taxonomy Name | Compounding Pharmacy
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License Number |
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License Number State |
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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 | PHRE009781
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License Number State | GA
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