1972666576 NPI number — BACON COUNTY HEALTH SVC INC

Table of content: (NPI 1972666576)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972666576 NPI number — BACON COUNTY HEALTH SVC INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BACON COUNTY HEALTH SVC 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:
BACON COUNTY HOSPITAL 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:
1972666576
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/04/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
302 S WAYNE ST
Provider Second Line Business Mailing Address:
PO DRAWER 1987
Provider Business Mailing Address City Name:
ALMA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31510-2922
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
302 S WAYNE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALMA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31510-2922
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-632-8961
Provider Business Practice Location Address Fax Number:
912-632-2231
Provider Enumeration Date:
12/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LOTT
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
Authorized Official Title or Position:
DIR OF PHRM SRV
Authorized Official Telephone Number:
912-632-8961

Provider Taxonomy Codes

  • Taxonomy code: 3336I0012X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336L0003X , with the licence number: 8086 , 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: 00000118B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2013239 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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