MEDICARE: FAIRYLAND PHARMACY 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	PHRE002347	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

General Provider Information

NPI Number	:	1245691534
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAIRYLAND PHARMACY INC

Provider Business Mailing Address
First Line	:	100 MCFARLAND RD
Second Line	:
City	:	LOOKOUT MTN
State	:	GA
Zip	:	30750-3121
Country	:	US
Telephone Number	:	706-820-1627
Fax Number	:	706-820-1164

Provider Business Practice Location Address
First Line	:	100 MCFARLAND RD
Second Line	:
City	:	LOOKOUT MTN
State	:	GA
Zip	:	30750-3121
Country	:	US
Telephone Number	:	706-820-1627
Fax Number	:	706-820-1164

Authorized Official
Title or Position	:	OWNER
Name	:	MR. ALAN MITCHELL VOGES JR.
Credential	:	RPH
Telephone Number	:	706-820-1627

Provider Enumeration Date	:	03/14/2016
Last Update Date	:	03/14/2016

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Directions to “FAIRYLAND PHARMACY INC ” Practice Location

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