Provider Demographics
NPI:1225143464
Name:1ST AMERICA DRUGS
Entity Type:Organization
Organization Name:1ST AMERICA DRUGS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:SUTTLES
Authorized Official - Last Name:HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:229-242-3060
Mailing Address - Street 1:212 NORTHSIDE DR
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-1858
Mailing Address - Country:US
Mailing Address - Phone:229-242-3060
Mailing Address - Fax:229-316-1366
Practice Address - Street 1:212 NORTHSIDE DR
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1858
Practice Address - Country:US
Practice Address - Phone:229-242-3060
Practice Address - Fax:229-316-1366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0064913336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00339248AMedicaid
GA0003314689OtherENVOY ID.