Provider Demographics
NPI:1083987457
Name:SGBS HOLDINGS LLC
Entity Type:Organization
Organization Name:SGBS HOLDINGS LLC
Other - Org Name:SOUTHERN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:GIRARDEAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-839-5456
Mailing Address - Street 1:606 BRANNEN ST STE B
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-5184
Mailing Address - Country:US
Mailing Address - Phone:912-225-9279
Mailing Address - Fax:
Practice Address - Street 1:606 BRANNEN ST STE B
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-5184
Practice Address - Country:US
Practice Address - Phone:912-225-9279
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-16
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
GAPHRE0098173336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1162116OtherNCPDP PROVIDER IDENTIFICATION NUMBER