MEDICARE: COWAN PHARMACY LLC

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	3336C0003X	Community/Retail Pharmacy	PHRE010400	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2177325	OTHER		PK

General Provider Information

NPI Number	:	1073521845
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COWAN PHARMACY LLC

Provider Business Mailing Address
First Line	:	1179 WEST AVE SW
Second Line	:
City	:	CONYERS
State	:	GA
Zip	:	30012-5280
Country	:	US
Telephone Number	:	770-929-1414
Fax Number	:	770-929-3002

Provider Business Practice Location Address
First Line	:	1179 WEST AVE SW
Second Line	:
City	:	CONYERS
State	:	GA
Zip	:	30012-5280
Country	:	US
Telephone Number	:	770-929-1414
Fax Number	:	770-929-3002

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ADAM MITCHAM
Credential	:
Telephone Number	:	770-929-1414

Provider Enumeration Date	:	08/04/2006
Last Update Date	:	07/19/2018

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Directions to “COWAN PHARMACY LLC ” Practice Location

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