Organization
OLDE TIME PHARMACY AT SIXES LLC
Active
Other names
Olde Time Pharmacy at Sixes, LLC
Organization subpart
No
Provider details
NPI number
Authorized official
SHAD SUTHERLAND (OWNER)
(770) 783-0483
Entity
Organization
Contact information
Practice address
684 SIXES RD STE 105, HOLLY SPRINGS, GA 30115-8720
(770) 783-0483
Mailing address
684 SIXES RD, SUITE 105, HOLLY SPRINGS, GA 30115-8721
(770) 783-0483
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
PHRE009711
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1160643
NCPDP PROVIDER IDENTIFICATION NUMBER
—
Enumeration date
11/12/2010
Last updated
12/01/2010
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