Provider Demographics
NPI:1043227929
Name:MIDDLE FLINT AREA COMMUNITY SERVICE BOARD
Entity Type:Organization
Organization Name:MIDDLE FLINT AREA COMMUNITY SERVICE BOARD
Other - Org Name:MIDDLE FLINT BEHAVIORAL HEALTH CARE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-815-5454
Mailing Address - Street 1:PO BOX 1348
Mailing Address - Street 2:
Mailing Address - City:AMERICUS
Mailing Address - State:GA
Mailing Address - Zip Code:31709-1348
Mailing Address - Country:US
Mailing Address - Phone:229-931-2470
Mailing Address - Fax:229-931-2474
Practice Address - Street 1:415 N JACKSON ST
Practice Address - Street 2:
Practice Address - City:AMERICUS
Practice Address - State:GA
Practice Address - Zip Code:31709-3015
Practice Address - Country:US
Practice Address - Phone:229-931-2470
Practice Address - Fax:229-931-2474
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MIDDLE FLINT AREA COMMUNITY SERVICE BOARD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-02
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE008689333600000X
3336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2015416OtherPK
GA734807561AMedicaid