Provider Demographics
NPI:1083132484
Name:VALDOSTA STATE UNIVERSITY
Entity Type:Organization
Organization Name:VALDOSTA STATE UNIVERSITY
Other - Org Name:VSU STUDENT HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LYNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-333-5886
Mailing Address - Street 1:200 GEORGIA AVE
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-3843
Mailing Address - Country:US
Mailing Address - Phone:229-219-3205
Mailing Address - Fax:229-249-2791
Practice Address - Street 1:200 GEORGIA AVE
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31698-3843
Practice Address - Country:US
Practice Address - Phone:229-219-3205
Practice Address - Fax:229-249-2791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-06
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE010386333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2170766OtherPK