Basic Information
Provider Information | |||||||||
NPI: | 1679195606 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TMC VILLA RICA HOSPITAL, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | NW GA ONCOLOGY CTR RETAIL PHARMACY - TMC/VILLA RICA | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 100 PROFESSIONAL PL STE 305 | ||||||||
Address2: |   | ||||||||
City: | CARROLLTON | ||||||||
State: | GA | ||||||||
PostalCode: | 301173872 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7708128614 | ||||||||
FaxNumber: | 7708128372 | ||||||||
Practice Location | |||||||||
Address1: | 157 CLINIC AVE STE 202, ROOM 219 | ||||||||
Address2: |   | ||||||||
City: | CARROLLTON | ||||||||
State: | GA | ||||||||
PostalCode: | 301174454 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7708121919 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/13/2020 | ||||||||
LastUpdateDate: | 09/08/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CREWS | ||||||||
AuthorizedOfficialFirstName: | CAROL | ||||||||
AuthorizedOfficialMiddleName: | S. | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 7708129745 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | TMC VILLA RICA HOSPITAL, INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | CFO | ||||||||
NPICertificationDate: | 09/08/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336S0011X |   |   | N |   | Suppliers | Pharmacy | Specialty Pharmacy | 3336C0003X |   |   | Y |   | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
ID | Type | State | Issuer | Description | 5KYKWKNF2 | 01 |   | HEALTH INDUSTRY NUMBER | OTHER |