1184618894 NPI number — COASTAL PHARMACY, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184618894 NPI number — COASTAL PHARMACY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COASTAL PHARMACY, INC.
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:
HINESVILLE PHARMACY
Provider Other Organization Name Type Code:
3
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:
1184618894
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/06/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1060
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RICHMOND HILL
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31324-1060
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-756-3331
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
481 ELMA G MILES PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HINESVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31313-4006
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-876-8125
Provider Business Practice Location Address Fax Number:
912-876-4387
Provider Enumeration Date:
09/08/2005

Additional Information

Authorized Official

Authorized Official Last Name:
TUCKER
Authorized Official First Name:
ALEX
Authorized Official Middle Name:
S
Authorized Official Title or Position:
PHARMACIST
Authorized Official Telephone Number:
912-756-3331

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  020913 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1104075 . This is a "NABP" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 119106408A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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