Provider Demographics
NPI:1053881623
Name:GWINNETT SUPPLY COMPANY LLC
Entity type:Organization
Organization Name:GWINNETT SUPPLY COMPANY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PARMI
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-469-9891
Mailing Address - Street 1:605 OLD NORCROSS RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-4315
Mailing Address - Country:US
Mailing Address - Phone:678-325-3331
Mailing Address - Fax:770-339-1859
Practice Address - Street 1:605 OLD NORCROSS RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-4315
Practice Address - Country:US
Practice Address - Phone:678-325-3331
Practice Address - Fax:770-339-1859
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-27
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPHRE010690OtherGA BOARD OF PHARMACY