Provider Demographics
NPI:1194780684
Name:VILLAGE DRUG SHOP OF ATHENS INC
Entity type:Organization
Organization Name:VILLAGE DRUG SHOP OF ATHENS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:THURMOND
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:706-548-4444
Mailing Address - Street 1:740 PRINCE AVE
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-5900
Mailing Address - Country:US
Mailing Address - Phone:706-548-4444
Mailing Address - Fax:706-548-2193
Practice Address - Street 1:740 PRINCE AVE
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-5900
Practice Address - Country:US
Practice Address - Phone:706-548-4444
Practice Address - Fax:706-548-2193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-19
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
GAPHRE0032453336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2015988OtherPK
GA00303509AMedicaid
2015988OtherPK