1326078007 NPI number — GUARDIAN PHARMACY OF SOUTHEAST GA LLC

Table of content: (NPI 1326078007)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326078007 NPI number — GUARDIAN PHARMACY OF SOUTHEAST GA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GUARDIAN PHARMACY OF SOUTHEAST GA 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:
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:
1326078007
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/12/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
GUARDIAN PHARMACY OF SOUTHEAST GEORGIA DEPT 2378
Provider Second Line Business Mailing Address:
P.O. BOX 11407
Provider Business Mailing Address City Name:
BIRMINGHAM
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35246-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-810-0089
Provider Business Mailing Address Fax Number:
404-810-0094

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10929 HWY 301 SOUTH
Provider Second Line Business Practice Location Address:
STE 110 111
Provider Business Practice Location Address City Name:
STATESBORO
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30458
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-764-7839
Provider Business Practice Location Address Fax Number:
912-489-1519
Provider Enumeration Date:
07/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DINELLO
Authorized Official First Name:
JODI
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
912-764-7839

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336L0003X , with the licence number: PHRE008143 , 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: 2013153 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 446858035A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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