Provider Demographics
NPI:1073568838
Name:UNISON BEHAVIORAL HEALTH PHARMACY
Entity Type:Organization
Organization Name:UNISON BEHAVIORAL HEALTH PHARMACY
Other - Org Name:SATILLA COMMUNITY SERVICES
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:MR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:SIMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:912-449-7147
Mailing Address - Street 1:1007 MARY STREET
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501
Mailing Address - Country:US
Mailing Address - Phone:912-449-7147
Mailing Address - Fax:912-449-7089
Practice Address - Street 1:1007 MARY STREET
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501
Practice Address - Country:US
Practice Address - Phone:912-449-7147
Practice Address - Fax:912-449-7089
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA251S00000X
GA56413336C0002X
3336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00611014AMedicaid
GAPHRE005641Medicaid
1115775OtherNABP