Provider Demographics
NPI:1174711170
Name:FOX PHARMACY LLC
Entity type:Organization
Organization Name:FOX PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANG MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:TRACEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-373-3918
Mailing Address - Street 1:905 PARKSIDE WALK LN
Mailing Address - Street 2:STE 108
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-7314
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:905 PARKSIDE WALK LN
Practice Address - Street 2:STE 108
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-7314
Practice Address - Country:US
Practice Address - Phone:678-373-3918
Practice Address - Fax:678-373-3921
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-04
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0004X
GAPHRE0093703336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1156389OtherOTHER ID NUMBER