Provider Demographics
NPI:1235108192
Name:PINELOG INC
Entity Type:Organization
Organization Name:PINELOG INC
Other - Org Name:HOBBS PHARMACY AND GIFTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:POTTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-228-2788
Mailing Address - Street 1:220 W COLLEGE ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30224-4121
Mailing Address - Country:US
Mailing Address - Phone:770-228-2788
Mailing Address - Fax:770-228-2789
Practice Address - Street 1:220 W COLLEGE ST
Practice Address - Street 2:SUITE D
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-4121
Practice Address - Country:US
Practice Address - Phone:770-228-2788
Practice Address - Fax:770-228-2789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-14
Last Update Date:2016-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
GAPHRE0009383336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000386295AMedicaid
2128412OtherPK