Provider Demographics
NPI:1164596680
Name:COLBERT PHARMACY INC 127 4TH ST
Entity Type:Organization
Organization Name:COLBERT PHARMACY INC 127 4TH ST
Other - Org Name:COLBERT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:706-788-2102
Mailing Address - Street 1:PO BOX 336
Mailing Address - Street 2:
Mailing Address - City:COLBERT
Mailing Address - State:GA
Mailing Address - Zip Code:30628-0336
Mailing Address - Country:US
Mailing Address - Phone:706-788-2102
Mailing Address - Fax:706-788-9470
Practice Address - Street 1:5674 HIGHWAY 72 W
Practice Address - Street 2:
Practice Address - City:COLBERT
Practice Address - State:GA
Practice Address - Zip Code:30628-2934
Practice Address - Country:US
Practice Address - Phone:706-788-2102
Practice Address - Fax:706-788-9740
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2011-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
GAPHRE0048383336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1102425OtherNCPDP PROVIDER IDENTIFICATION NUMBER
GA00025165AMedicaid