Provider Demographics
NPI:1104836493
Name:BAINBRIDGE PHARMACY INC.
Entity Type:Organization
Organization Name:BAINBRIDGE PHARMACY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:F
Authorized Official - Last Name:REYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:229-246-7200
Mailing Address - Street 1:1420 E EVANS ST
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:39819-4336
Mailing Address - Country:US
Mailing Address - Phone:229-246-7200
Mailing Address - Fax:229-246-6210
Practice Address - Street 1:1420 E EVANS ST
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:39819-4336
Practice Address - Country:US
Practice Address - Phone:229-246-7200
Practice Address - Fax:229-246-6210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2011-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336H0001X
GAPHRE0028523336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000355429AMedicaid
GA000355429AMedicaid