Provider Demographics
NPI:1063407807
Name:TOWN AND CAMPUS RETAILERS, INC.
Entity type:Organization
Organization Name:TOWN AND CAMPUS RETAILERS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:F
Authorized Official - Last Name:GAY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:912-764-6454
Mailing Address - Street 1:22 S ZETTEROWER AVE
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-4866
Mailing Address - Country:US
Mailing Address - Phone:912-764-6454
Mailing Address - Fax:912-489-1110
Practice Address - Street 1:22 S ZETTEROWER AVE
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-4866
Practice Address - Country:US
Practice Address - Phone:912-764-6454
Practice Address - Fax:912-489-1110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-19
Last Update Date:2008-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE006877333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0157330001Medicare NSC