Provider Demographics
NPI:1144308552
Name:CHANCY DRUGS HAHIRA LLC
Entity type:Organization
Organization Name:CHANCY DRUGS HAHIRA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:BETH
Authorized Official - Middle Name:
Authorized Official - Last Name:ROUNTREE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-794-2750
Mailing Address - Street 1:205 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HAHIRA
Mailing Address - State:GA
Mailing Address - Zip Code:31632-1121
Mailing Address - Country:US
Mailing Address - Phone:229-794-2750
Mailing Address - Fax:229-794-4092
Practice Address - Street 1:205 E MAIN ST
Practice Address - Street 2:
Practice Address - City:HAHIRA
Practice Address - State:GA
Practice Address - Zip Code:31632-1121
Practice Address - Country:US
Practice Address - Phone:229-794-2750
Practice Address - Fax:229-794-4092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2015-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336L0003X, 3336S0011X, 333600000X
GAPHRE0031283336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00023053AMedicaid
2012397OtherPK