Provider Demographics
NPI:1841623808
Name:GEORGE COUNTY PHARMACY
Entity type:Organization
Organization Name:GEORGE COUNTY PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DOP
Authorized Official - Prefix:
Authorized Official - First Name:CARMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-673-6181
Mailing Address - Street 1:92 RATLIFF ST
Mailing Address - Street 2:
Mailing Address - City:LUCEDALE
Mailing Address - State:MS
Mailing Address - Zip Code:39452-6537
Mailing Address - Country:US
Mailing Address - Phone:601-673-6181
Mailing Address - Fax:601-766-4293
Practice Address - Street 1:92 RATLIFF ST
Practice Address - Street 2:
Practice Address - City:LUCEDALE
Practice Address - State:MS
Practice Address - Zip Code:39452-6537
Practice Address - Country:US
Practice Address - Phone:601-673-6181
Practice Address - Fax:601-766-4293
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-14
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336I0012X, 3336L0003X
MS12325/2.63336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2140621OtherPK