Provider Demographics
NPI:1316976467
Name:CAMILLA PHARMACY INC
Entity type:Organization
Organization Name:CAMILLA PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LEN
Authorized Official - Middle Name:F
Authorized Official - Last Name:REYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:229-336-8474
Mailing Address - Street 1:PO BOX 33
Mailing Address - Street 2:
Mailing Address - City:CAMILLA
Mailing Address - State:GA
Mailing Address - Zip Code:31730-0033
Mailing Address - Country:US
Mailing Address - Phone:229-336-8474
Mailing Address - Fax:229-336-5602
Practice Address - Street 1:92 E BROAD ST
Practice Address - Street 2:
Practice Address - City:CAMILLA
Practice Address - State:GA
Practice Address - Zip Code:31730-1832
Practice Address - Country:US
Practice Address - Phone:229-336-8474
Practice Address - Fax:229-336-5602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE003289332B00000X, 183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1107235OtherNCPDP
GA00022701AMedicaid
GA00022701BMedicaid
GA00022701BMedicaid