Provider Demographics
NPI:1407963069
Name:AMERICUS & SUMTER COUNTY HOSPITAL AUTHORITY
Entity Type:Organization
Organization Name:AMERICUS & SUMTER COUNTY HOSPITAL AUTHORITY
Other - Org Name:SUMTER REGIONAL HOSPITAL PHCY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIR OF PHCY
Authorized Official - Prefix:
Authorized Official - First Name:DARRYL
Authorized Official - Middle Name:
Authorized Official - Last Name:HAWKINS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:229-931-1265
Mailing Address - Street 1:100 WHEATLEY DR
Mailing Address - Street 2:
Mailing Address - City:AMERICUS
Mailing Address - State:GA
Mailing Address - Zip Code:31709-3788
Mailing Address - Country:US
Mailing Address - Phone:229-931-1265
Mailing Address - Fax:229-931-1175
Practice Address - Street 1:100 WHEATLEY DR
Practice Address - Street 2:
Practice Address - City:AMERICUS
Practice Address - State:GA
Practice Address - Zip Code:31709-3788
Practice Address - Country:US
Practice Address - Phone:229-931-1265
Practice Address - Fax:229-931-1175
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0063573336I0012X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00679511AMedicaid
1136185OtherNCPDP PROVIDER IDENTIFICATION NUMBER