Provider Demographics
NPI:1285722710
Name:SELF-MED RX CLAYTON DRUG INC
Entity type:Organization
Organization Name:SELF-MED RX CLAYTON DRUG INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:ADDINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-782-3211
Mailing Address - Street 1:PO BOX 686
Mailing Address - Street 2:C/O SEF MED RX
Mailing Address - City:CLAYTON
Mailing Address - State:GA
Mailing Address - Zip Code:30525
Mailing Address - Country:US
Mailing Address - Phone:706-782-3211
Mailing Address - Fax:
Practice Address - Street 1:100 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:GA
Practice Address - Zip Code:30525-5480
Practice Address - Country:US
Practice Address - Phone:706-782-3211
Practice Address - Fax:706-782-0705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
GAPHRE0027103336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00025033AMedicaid
2012111OtherPK
1291190001Medicare NSC