Provider Demographics
NPI:1174627426
Name:COLLEGE PHARMACY, INC.
Entity Type:Organization
Organization Name:COLLEGE PHARMACY, INC.
Other - Org Name:EAST GEORGIA HOME CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:GUERNSEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-489-4663
Mailing Address - Street 1:35 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-5245
Mailing Address - Country:US
Mailing Address - Phone:912-489-4663
Mailing Address - Fax:912-489-3129
Practice Address - Street 1:35 S MAIN ST
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-5245
Practice Address - Country:US
Practice Address - Phone:912-489-4663
Practice Address - Fax:912-489-3129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-08
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332BP3500X, 332BX2000X
GAPHRE0077673336H0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0593130001Medicare NSC