MEDICARE: OLD ROSWELL HOLDINGS 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	332B00000X	Durable Medical Equipment & Medical Supplies
2	3336L0003X	Long Term Care Pharmacy
3	3336L0003X	Long Term Care Pharmacy	PP481575	PA

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	:	1619240025
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OLD ROSWELL HOLDINGS LLC

Provider Business Mailing Address
First Line	:	5064 ROSWELL RD STE A200
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30342-2252
Country	:	US
Telephone Number	:	404-459-8005
Fax Number	:	404-259-5517

Provider Business Practice Location Address
First Line	:	3913 HARTZDALE DR
Second Line	:	SUITE 1306
City	:	CAMP HILL
State	:	PA
Zip	:	17011-7845
Country	:	US
Telephone Number	:	717-766-6191
Fax Number	:	717-691-1052

Authorized Official
Title or Position	:	MANAGER
Name	:	TRACY EDEN
Credential	:
Telephone Number	:	404-459-8005

Provider Enumeration Date	:	02/15/2012
Last Update Date	:	04/29/2025

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