Provider Demographics
NPI:1699846618
Name:YW PROFESSIONAL AND PFC TRADING ALLIANCE INC
Entity type:Organization
Organization Name:YW PROFESSIONAL AND PFC TRADING ALLIANCE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:GEN MGR
Authorized Official - Prefix:
Authorized Official - First Name:ALEC
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:770-455-8882
Mailing Address - Street 1:5150 BUFORD HWY NE
Mailing Address - Street 2:STE B180
Mailing Address - City:DORAVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30340-1153
Mailing Address - Country:US
Mailing Address - Phone:770-455-8882
Mailing Address - Fax:770-455-8806
Practice Address - Street 1:5150 BUFORD HWY NE
Practice Address - Street 2:STE B180
Practice Address - City:DORAVILLE
Practice Address - State:GA
Practice Address - Zip Code:30340-1153
Practice Address - Country:US
Practice Address - Phone:770-455-8882
Practice Address - Fax:770-455-8806
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
GAPHRE0078683336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2019126OtherPK
GA000653243AMedicaid