Provider Demographics
NPI:1083722151
Name:OLD ROSWELL HOLDINGS LLC
Entity type:Organization
Organization Name:OLD ROSWELL HOLDINGS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:EDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-459-8005
Mailing Address - Street 1:5064 ROSWELL RD STE A200
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-2252
Mailing Address - Country:US
Mailing Address - Phone:404-459-8005
Mailing Address - Fax:404-256-5517
Practice Address - Street 1:1179 VESTAL AVE
Practice Address - Street 2:STE. 1
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13903-1606
Practice Address - Country:US
Practice Address - Phone:607-723-7585
Practice Address - Fax:607-773-0936
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-28
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024755333600000X
NY3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY3327637OtherNCPDP #
NY02734325Medicaid
NY3327637OtherNCPDP #
NY3860220010Medicare NSC