Provider Demographics
NPI:1235121617
Name:COMMUNITY ANCILLARY SERVICES, INC.
Entity Type:Organization
Organization Name:COMMUNITY ANCILLARY SERVICES, INC.
Other - Org Name:ELDERCARE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-783-1515
Mailing Address - Street 1:PO BOX 1038
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-8938
Mailing Address - Country:US
Mailing Address - Phone:770-974-4277
Mailing Address - Fax:770-974-4208
Practice Address - Street 1:4769 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30101-5339
Practice Address - Country:US
Practice Address - Phone:770-974-4277
Practice Address - Fax:770-974-4208
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-22
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
GAPHRE0080753336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00811478AMedicaid
2020178OtherPK
GA00811478AMedicaid