Provider Demographics
NPI:1285934059
Name:BARNES DRUG STORES OF VALDOSTA, INC
Entity type:Organization
Organization Name:BARNES DRUG STORES OF VALDOSTA, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:BARNES
Authorized Official - Suffix:IV
Authorized Official - Credentials:
Authorized Official - Phone:229-245-6039
Mailing Address - Street 1:PO BOX 1187
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31603-1187
Mailing Address - Country:US
Mailing Address - Phone:229-245-6039
Mailing Address - Fax:
Practice Address - Street 1:2030 POWERS FERRY RD SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30339-2823
Practice Address - Country:US
Practice Address - Phone:678-627-0077
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-27
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA333600000X
3336H0001X, 3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
No333600000XSuppliersPharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003100979AMedicaid
GA000021645IMedicaid