Provider Demographics
NPI:1053357509
Name:LONGS DRUGS OF SANDERSVILLE GEORGIA INC
Entity type:Organization
Organization Name:LONGS DRUGS OF SANDERSVILLE GEORGIA INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:CODY
Authorized Official - Last Name:COLQUITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-592-2011
Mailing Address - Street 1:5700 GRANITE PARKWAY
Mailing Address - Street 2:SUITE 425
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024-6648
Mailing Address - Country:US
Mailing Address - Phone:469-592-2011
Mailing Address - Fax:404-231-5677
Practice Address - Street 1:2140 PEACHTREE RD NW
Practice Address - Street 2:SUITE 232
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1316
Practice Address - Country:US
Practice Address - Phone:404-231-4431
Practice Address - Fax:404-231-5677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0002X
GAPHRE0097023336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1148279OtherNCPDP PROVIDER IDENTIFICATION NUMBER
GA003291812AMedicaid