Provider Demographics
NPI:1134563406
Name:LILBURN COMMUNITY PHARMACY
Entity type:Organization
Organization Name:LILBURN COMMUNITY PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/ORGANIZER
Authorized Official - Prefix:
Authorized Official - First Name:SAMINA
Authorized Official - Middle Name:C
Authorized Official - Last Name:KHATRI
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACY
Authorized Official - Phone:770-710-0478
Mailing Address - Street 1:2147 WHITESTONE CT SE
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-3116
Mailing Address - Country:US
Mailing Address - Phone:404-909-8052
Mailing Address - Fax:
Practice Address - Street 1:4025 LAWRENCEVILLE HWY NW STE D
Practice Address - Street 2:
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-2876
Practice Address - Country:US
Practice Address - Phone:770-710-0478
Practice Address - Fax:770-710-0861
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-17
Last Update Date:2024-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336S0011X
GAPHRE0099173336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2139893OtherPK
GA003133182AMedicaid
GA003133182AMedicaid