Provider Demographics
NPI:1285058651
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 1:5225 WILSON LN
Practice Address - Street 2:
Practice Address - City:MECHANICSBURG
Practice Address - State:PA
Practice Address - Zip Code:17055-6663
Practice Address - Country:US
Practice Address - Phone:717-516-3103
Practice Address - Fax:717-516-3104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-06
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336L0003X
PAPP4811293336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2144834OtherPK
3860220022Medicare NSC
3860220022Medicare NSC