Provider Demographics
NPI:1114012119
Name:SUMMERVILLE PHARMACY
Entity type:Organization
Organization Name:SUMMERVILLE PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/ PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:HANI
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:MUSSAD
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:706-481-7140
Mailing Address - Street 1:2258 WRIGHTSBORO RD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904
Mailing Address - Country:US
Mailing Address - Phone:706-481-7140
Mailing Address - Fax:706-733-7301
Practice Address - Street 1:3087 WESTWOOD RD
Practice Address - Street 2:HANI MUSSAD
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909
Practice Address - Country:US
Practice Address - Phone:706-736-2093
Practice Address - Fax:706-733-7301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH.004193333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy