Provider Demographics
NPI:1194742890
Name:SANDY SPRINGS PHARMACY
Entity type:Organization
Organization Name:SANDY SPRINGS PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:404-252-8165
Mailing Address - Street 1:6329 ROSWELL RD NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-3225
Mailing Address - Country:US
Mailing Address - Phone:404-252-8165
Mailing Address - Fax:
Practice Address - Street 1:6329 ROSWELL RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-3225
Practice Address - Country:US
Practice Address - Phone:404-252-8165
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE004962183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0035472DMedicaid
GA0035472DMedicaid