Provider Demographics
NPI:1437488426
Name:PALMETTO HEALTH COUNCIL, INC.
Entity Type:Organization
Organization Name:PALMETTO HEALTH COUNCIL, INC.
Other - Org Name:PALMETTO HEALTH COUNCIL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:W
Authorized Official - Last Name:WOLLENZIEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-929-8824
Mailing Address - Street 1:643 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PALMETTO
Mailing Address - State:GA
Mailing Address - Zip Code:30268-1138
Mailing Address - Country:US
Mailing Address - Phone:404-929-8824
Mailing Address - Fax:404-929-9769
Practice Address - Street 1:643 MAIN ST
Practice Address - Street 2:
Practice Address - City:PALMETTO
Practice Address - State:GA
Practice Address - Zip Code:30268-1138
Practice Address - Country:US
Practice Address - Phone:770-567-0334
Practice Address - Fax:770-626-4091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-22
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0096233336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1159587OtherNCPDP PROVIDER IDENTIFICATION NUMBER