Provider Demographics
NPI:1154546646
Name:HARTWELL RX INC
Entity type:Organization
Organization Name:HARTWELL RX INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER, AO
Authorized Official - Prefix:
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-376-5801
Mailing Address - Street 1:118 ATHENS ST
Mailing Address - Street 2:
Mailing Address - City:HARTWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30643-1851
Mailing Address - Country:US
Mailing Address - Phone:706-376-5801
Mailing Address - Fax:706-376-8687
Practice Address - Street 1:118 ATHENS ST
Practice Address - Street 2:
Practice Address - City:HARTWELL
Practice Address - State:GA
Practice Address - Zip Code:30643-1851
Practice Address - Country:US
Practice Address - Phone:706-376-5801
Practice Address - Fax:706-376-8687
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
GAPHRE0096353336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2124561OtherPK
GA601505588AMedicaid