Provider Demographics
NPI:1528478328
Name:CLEVELAND DRUG CO INC
Entity type:Organization
Organization Name:CLEVELAND DRUG CO INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:REGISTERED PHARMACIST/CO-OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:HALEY
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:706-219-2626
Mailing Address - Street 1:184 WEST KYTLE STREET
Mailing Address - Street 2:SUITE A
Mailing Address - City:CLEVELAND
Mailing Address - State:GA
Mailing Address - Zip Code:30528
Mailing Address - Country:US
Mailing Address - Phone:706-219-2626
Mailing Address - Fax:706-219-1253
Practice Address - Street 1:184 WEST KYTLE STREET
Practice Address - Street 2:SUITE A
Practice Address - City:CLEVELAND
Practice Address - State:GA
Practice Address - Zip Code:30528
Practice Address - Country:US
Practice Address - Phone:706-219-2626
Practice Address - Fax:706-219-1253
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003148048AMedicaid