Provider Demographics
NPI:1124100912
Name:FIRST AMERICA PHARMACY INC
Entity type:Organization
Organization Name:FIRST AMERICA PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:C
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:JR
Authorized Official - Credentials:RPH
Authorized Official - Phone:229-253-0067
Mailing Address - Street 1:3782 OLD US HIGHWAY 41 N
Mailing Address - Street 2:SUITE B
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-6834
Mailing Address - Country:US
Mailing Address - Phone:229-253-0067
Mailing Address - Fax:229-253-9010
Practice Address - Street 1:3782 OLD US HIGHWAY 41 N
Practice Address - Street 2:SUITE B
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-6834
Practice Address - Country:US
Practice Address - Phone:229-253-0067
Practice Address - Fax:229-253-9010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
GAPHRE006796333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1110624OtherOTHER ID NUMBER-COMMERCIAL NUMBER
GA00768501AMedicaid
1110624OtherOTHER ID NUMBER-COMMERCIAL NUMBER