1295729861 NPI number — SOUTH GEORGIA PHARMACY SERVICES INC

Table of content: (NPI 1295729861)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295729861 NPI number — SOUTH GEORGIA PHARMACY SERVICES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH GEORGIA PHARMACY SERVICES 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:
CONVENIENT CARE PHARMACY #2
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:
1295729861
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/23/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 861
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOULTRIE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31776-0861
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
229-890-6054
Provider Business Mailing Address Fax Number:
229-891-4087

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
720 W CENTRAL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOULTRIE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31768-3560
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
229-890-6054
Provider Business Practice Location Address Fax Number:
229-891-4087
Provider Enumeration Date:
09/09/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
YARBROUGH
Authorized Official First Name:
GREGORY
Authorized Official Middle Name:
L
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
229-890-6054

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1145932 . This is a "NACDS PROVIDER #" identifier . This identifiers is of the category "OTHER".
  • Identifier: 00814173A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".