Provider Demographics
NPI:1932368974
Name:MCINTOSH TRAIL CSB
Entity type:Organization
Organization Name:MCINTOSH TRAIL CSB
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCOLLUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-358-8251
Mailing Address - Street 1:136 N HILL ST
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30223-3335
Mailing Address - Country:US
Mailing Address - Phone:770-229-3000
Mailing Address - Fax:
Practice Address - Street 1:1501A KALAMAZOO DR
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-3919
Practice Address - Country:US
Practice Address - Phone:770-358-8250
Practice Address - Fax:770-229-3223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-05
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0052293336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1123645OtherNCPDP
GA000251666AMedicaid