1073568838 NPI number — UNISON BEHAVIORAL HEALTH PHARMACY

Table of content: (NPI 1073568838)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073568838 NPI number — UNISON BEHAVIORAL HEALTH PHARMACY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UNISON BEHAVIORAL HEALTH PHARMACY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SATILLA COMMUNITY SERVICES
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073568838
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/30/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1007 MARY STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAYCROSS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-449-7147
Provider Business Mailing Address Fax Number:
912-449-7089

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1007 MARY STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAYCROSS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-449-7147
Provider Business Practice Location Address Fax Number:
912-449-7089
Provider Enumeration Date:
05/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SIMPSON
Authorized Official First Name:
HENRY
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
PHARMACIST IN CHARGE
Authorized Official Telephone Number:
912-449-7147

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0002X , with the licence number: 5641 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00611014A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: PHRE005641 , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1115775 . This is a "NABP" identifier . This identifiers is of the category "OTHER".




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