MEDICARE: LONGS DRUGS OF SANDERSVILLE GEORGIA INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336C0002X	Clinic Pharmacy
3	3336C0003X	Community/Retail Pharmacy	PHRE009702	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1148279	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053357509
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LONGS DRUGS OF SANDERSVILLE GEORGIA INC

Provider Business Mailing Address
First Line	:	5700 GRANITE PARKWAY
Second Line	:	SUITE 425
City	:	PLANO
State	:	TX
Zip	:	75024-6648
Country	:	US
Telephone Number	:	469-592-2011
Fax Number	:	404-231-5677

Provider Business Practice Location Address
First Line	:	2140 PEACHTREE RD NW
Second Line	:	SUITE 232
City	:	ATLANTA
State	:	GA
Zip	:	30309-1316
Country	:	US
Telephone Number	:	404-231-4431
Fax Number	:	404-231-5677

Authorized Official
Title or Position	:	CHIEF FINANCIAL OFFICER
Name	:	CARL CODY COLQUITT
Credential	:
Telephone Number	:	469-592-2011

Provider Enumeration Date	:	06/22/2006
Last Update Date	:	09/12/2025

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