1144387416 NPI number — SOUTHERN MOODYCARE INC

Table of content: (NPI 1144387416)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144387416 NPI number — SOUTHERN MOODYCARE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN MOODYCARE 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:
Provider Other Organization Name Type Code:
6
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:
1144387416
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/24/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 506
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ARLINGTON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
39813-0506
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:
84 MAXWELL ST SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ARLINGTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
39813-8712
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
229-725-4212
Provider Business Practice Location Address Fax Number:
229-725-5242
Provider Enumeration Date:
01/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MOODY
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/OWNER/PHARMACIST
Authorized Official Telephone Number:
478-745-5431

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  PHRE004054 , 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: 2134212 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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