1669580916 NPI number — J H HARVEY CO LLC

Table of content: (NPI 1669580916)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669580916 NPI number — J H HARVEY CO LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
J H HARVEY CO LLC
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:
HARVEYS SUPERMARKET PHARMACY #2306
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:
1669580916
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/11/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1000
Provider Second Line Business Mailing Address:
MS3000
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04104-5005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-885-7454
Provider Business Mailing Address Fax Number:
207-396-2028

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
813 PETERSON AVE S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DOUGLAS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31533-5234
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-383-6862
Provider Business Practice Location Address Fax Number:
912-383-6745
Provider Enumeration Date:
08/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FAIRBANKS
Authorized Official First Name:
COURTNEY
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACY INSURANCE SPECIALIST
Authorized Official Telephone Number:
207-885-7454

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 991274720A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1153321 . This is a "OTHER ID NUMBER-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".




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