Provider Demographics
NPI:1871623975
Name:COLONY PRESCRIPTION SHOP
Entity type:Organization
Organization Name:COLONY PRESCRIPTION SHOP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:W
Authorized Official - Last Name:RUSS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:229-686-2088
Mailing Address - Street 1:1230 E MCPHERSON ST
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31639-2369
Mailing Address - Country:US
Mailing Address - Phone:229-686-2088
Mailing Address - Fax:229-686-2088
Practice Address - Street 1:1230 E MCPHERSON ST
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:GA
Practice Address - Zip Code:31639-2369
Practice Address - Country:US
Practice Address - Phone:229-686-2088
Practice Address - Fax:229-686-2088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2008-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0055813336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000025242AMedicaid
GA000025242AMedicaid