Provider Demographics
NPI:1144387416
Name:SOUTHERN MOODYCARE INC
Entity Type:Organization
Organization Name:SOUTHERN MOODYCARE INC
Other - Org Name:ARLINGTON REXALL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:MOODY
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:478-745-5431
Mailing Address - Street 1:PO BOX 506
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:39813-0506
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:84 MAXWELL ST SE
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:GA
Practice Address - Zip Code:39813-8712
Practice Address - Country:US
Practice Address - Phone:229-725-4212
Practice Address - Fax:229-725-5242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0040543336C0003X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2134212OtherPK
0831490001Medicare NSC
GA00021348BMedicaid
1104544OtherNCPDP PROVIDER IDENTIFICATION NUMBER