Provider Demographics
NPI:1033273081
Name:PORTER PHARMACY & GIFTS, INC.
Entity Type:Organization
Organization Name:PORTER PHARMACY & GIFTS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STAFF PHARMACIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:DYKES
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:478-934-6344
Mailing Address - Street 1:134 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:COCHRAN
Mailing Address - State:GA
Mailing Address - Zip Code:31014-6304
Mailing Address - Country:US
Mailing Address - Phone:478-934-6344
Mailing Address - Fax:478-934-8820
Practice Address - Street 1:134 N 2ND ST
Practice Address - Street 2:
Practice Address - City:COCHRAN
Practice Address - State:GA
Practice Address - Zip Code:31014-6304
Practice Address - Country:US
Practice Address - Phone:478-934-6344
Practice Address - Fax:478-934-8820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0057953336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000363701AMedicaid
GA300026936AMedicaid
GA1267040001Medicare NSC