=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891106605
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OLD NATIONAL DRUG PHARMACY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/14/2014
-----------------------------------------------------
Last Update Date | 05/14/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5615 OLD NATIONAL HWY B
-----------------------------------------------------
City | COLLEGE PARK
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30349-3811
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-209-0070
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5615 OLD NATIONAL HWY B
-----------------------------------------------------
City | COLLEGE PARK
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30349-3811
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-209-0070
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST IN CHARGE
-----------------------------------------------------
Name | SHARI HARRIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 404-402-8385
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | PHR010012
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------