Provider Demographics
NPI:1548471055
Name:ROYAL PHARMACY
Entity type:Organization
Organization Name:ROYAL PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER AND PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:ROYAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-382-0480
Mailing Address - Street 1:1620 JOHN ORR DR
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-3641
Mailing Address - Country:US
Mailing Address - Phone:229-382-0480
Mailing Address - Fax:229-388-8258
Practice Address - Street 1:1620 JOHN ORR DR
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-3641
Practice Address - Country:US
Practice Address - Phone:229-382-0480
Practice Address - Fax:229-388-8258
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-25
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
GAPHRE0029913336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00035329AMedicaid
1114951OtherNCPDP PROVIDER IDENTIFICATION NUMBER