Provider Demographics
NPI:1164730669
Name:DENNARD INC
Entity Type:Organization
Organization Name:DENNARD INC
Other - Org Name:DENNARDS LTC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BLAKE
Authorized Official - Middle Name:
Authorized Official - Last Name:DENNARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-529-2021
Mailing Address - Street 1:804 SECOND ST
Mailing Address - Street 2:
Mailing Address - City:SOPERTON
Mailing Address - State:GA
Mailing Address - Zip Code:30457-2402
Mailing Address - Country:US
Mailing Address - Phone:912-529-2021
Mailing Address - Fax:912-529-2031
Practice Address - Street 1:804 SECOND ST
Practice Address - Street 2:
Practice Address - City:SOPERTON
Practice Address - State:GA
Practice Address - Zip Code:30457-2402
Practice Address - Country:US
Practice Address - Phone:912-529-2021
Practice Address - Fax:912-529-2031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-17
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
GAPHRE0096833336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003100424AMedicaid
2126572OtherPK