Provider Demographics
NPI:1871570275
Name:EGOR ENTERPRISES, INC
Entity type:Organization
Organization Name:EGOR ENTERPRISES, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:DAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:706-277-2507
Mailing Address - Street 1:1102 W WAUGH ST
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-8769
Mailing Address - Country:US
Mailing Address - Phone:706-277-2507
Mailing Address - Fax:706-277-2536
Practice Address - Street 1:1100 E WALNUT AVE
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30721-4183
Practice Address - Country:US
Practice Address - Phone:706-226-6000
Practice Address - Fax:706-226-3786
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0089373336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPHRE008937OtherSTATE PHARMACY LICENSE
GA00932588CMedicaid
GA00932588DMedicaid
GA00932588DMedicaid
GABF9308900OtherDEA NUMBER
GABF9308900OtherDEA NUMBER