Provider Demographics
NPI:1962777458
Name:RED CARPET MEDICAL
Entity type:Organization
Organization Name:RED CARPET MEDICAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JIMI
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAROMI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-529-9277
Mailing Address - Street 1:3450 COBB PKWY NW STE 110
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-8376
Mailing Address - Country:US
Mailing Address - Phone:770-529-9277
Mailing Address - Fax:
Practice Address - Street 1:3450 COBB PKWY NW STE 110
Practice Address - Street 2:
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30101-8376
Practice Address - Country:US
Practice Address - Phone:770-529-9277
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-15
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336S0011X
GAPHRE0098553336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2135105OtherPK
GA003127687AMedicaid