Provider Demographics
NPI:1386626570
Name:SOUTH GEORGIA MEDICAL CENTER
Entity Type:Organization
Organization Name:SOUTH GEORGIA MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:M
Authorized Official - Last Name:BRANNEN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:229-259-4869
Mailing Address - Street 1:2501 NORTH PATTERSON STREET
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31603-1727
Mailing Address - Country:US
Mailing Address - Phone:229-259-4869
Mailing Address - Fax:229-259-4872
Practice Address - Street 1:2501 NORTH PATTERSON STREET
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31603-1727
Practice Address - Country:US
Practice Address - Phone:229-259-4869
Practice Address - Fax:229-259-4872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHH004025333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPHH004025OtherPHARMACY LICENSE #
GAPHH004025OtherPHARMACY LICENSE #