=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881133064
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | A & A PHARMACY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/21/2017
-----------------------------------------------------
Last Update Date | 02/21/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4683 LOG CABIN DR
-----------------------------------------------------
City | MACON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31204-6317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-284-1028
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 404 BARRINGTON HALL DR
-----------------------------------------------------
City | MACON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31220-0703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-284-1028
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACY MANAGER/PRESIDENT
-----------------------------------------------------
Name | VIJAY PATEL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 478-284-1028
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PHRE010340
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------