Provider Demographics
NPI:1306105325
Name:MARKETPLACE PHARMACY LLC
Entity type:Organization
Organization Name:MARKETPLACE PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:706-384-2085
Mailing Address - Street 1:PO BOX 355
Mailing Address - Street 2:9205 LAVONIA RD.
Mailing Address - City:CARNESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30521
Mailing Address - Country:US
Mailing Address - Phone:706-384-2085
Mailing Address - Fax:706-384-2225
Practice Address - Street 1:9205 LAVONIA RD
Practice Address - Street 2:
Practice Address - City:CARNESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30521-3203
Practice Address - Country:US
Practice Address - Phone:706-384-3995
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-10
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE010393333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy