1265651103 NPI number — BARNES DRUG STORES OF VALDOSTA, INC

Table of content: (NPI 1265651103)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265651103 NPI number — BARNES DRUG STORES OF VALDOSTA, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BARNES DRUG STORES OF VALDOSTA, 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:
1265651103
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/27/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1187
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VALDOSTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31603-1187
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
229-245-6039
Provider Business Mailing Address Fax Number:
888-276-7881

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2875 KNIGHT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAYCROSS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31503-9555
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-284-9191
Provider Business Practice Location Address Fax Number:
912-285-4567
Provider Enumeration Date:
04/25/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BARNES
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER AND CEO
Authorized Official Telephone Number:
229-245-6039

Provider Taxonomy Codes

  • Taxonomy code: 332BX2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000021645F , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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