Provider Demographics
NPI:1376682849
Name:UNIVERSITY CANCER & BLOOD CENTER, LLC
Entity Type:Organization
Organization Name:UNIVERSITY CANCER & BLOOD CENTER, LLC
Other - Org Name:NORTHEAST GEORGIA CANCER CARE, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:SARA
Authorized Official - Middle Name:
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:706-543-4344
Mailing Address - Street 1:3320 OLD JEFFERSON RD
Mailing Address - Street 2:BLDG 700A
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30607-1465
Mailing Address - Country:US
Mailing Address - Phone:706-353-4344
Mailing Address - Fax:706-353-4355
Practice Address - Street 1:3320 OLD JEFFERSON RD BLDG 800A
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30607-1400
Practice Address - Country:US
Practice Address - Phone:706-353-4344
Practice Address - Fax:706-353-4355
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNIVERSITY CANCER & BLOOD CENTER, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-05
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
GA3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1153054OtherNCPDP
GA469992514BMedicaid
GAGRP6982Medicare PIN
GA469992514BMedicaid