Provider Demographics
NPI:1386949550
Name:DJK 36 INC
Entity type:Organization
Organization Name:DJK 36 INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KISER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-472-7561
Mailing Address - Street 1:PO BOX 250
Mailing Address - Street 2:
Mailing Address - City:MONTEZUMA
Mailing Address - State:GA
Mailing Address - Zip Code:31063-0250
Mailing Address - Country:US
Mailing Address - Phone:478-472-7561
Mailing Address - Fax:478-472-5887
Practice Address - Street 1:112 S DOOLY ST
Practice Address - Street 2:
Practice Address - City:MONTEZUMA
Practice Address - State:GA
Practice Address - Zip Code:31063-1604
Practice Address - Country:US
Practice Address - Phone:478-472-7561
Practice Address - Fax:478-472-5887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-20
Last Update Date:2011-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0033933336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00927649AMedicaid
1161063OtherNCPDP PROVIDER IDENTIFICATION NUMBER
GA6492250001Medicare NSC