Provider Demographics
NPI:1376558916
Name:TERESE INC
Entity Type:Organization
Organization Name:TERESE INC
Other - Org Name:PEACH ORCHARD DRUGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TERESE
Authorized Official - Middle Name:
Authorized Official - Last Name:FORDHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-533-3369
Mailing Address - Street 1:2529 PEACH ORCHARD RD
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30906-2412
Mailing Address - Country:US
Mailing Address - Phone:706-798-3253
Mailing Address - Fax:706-798-3225
Practice Address - Street 1:2529 PEACH ORCHARD RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30906-2412
Practice Address - Country:US
Practice Address - Phone:706-798-3253
Practice Address - Fax:706-798-3225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2015-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
GAPHRE0090103336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2016259OtherPK
GA787683075AMedicaid
5696640001Medicare NSC