Provider Demographics
NPI:1720810500
Name:MEDICAL CENTER PRESCRIPTION SHOP
Entity type:Organization
Organization Name:MEDICAL CENTER PRESCRIPTION SHOP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:T
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-374-6662
Mailing Address - Street 1:710 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:EASTMAN
Mailing Address - State:GA
Mailing Address - Zip Code:31023-6736
Mailing Address - Country:US
Mailing Address - Phone:478-374-5514
Mailing Address - Fax:
Practice Address - Street 1:710 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:EASTMAN
Practice Address - State:GA
Practice Address - Zip Code:31023-6736
Practice Address - Country:US
Practice Address - Phone:478-374-5514
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRESCRIPTION SHOP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-08-19
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy