Provider Demographics
NPI:1467430819
Name:JOHN D. ARCHBOLD MEMORIAL HOSPITAL, INC.
Entity Type:Organization
Organization Name:JOHN D. ARCHBOLD MEMORIAL HOSPITAL, INC.
Other - Org Name:ARCHBOLD PINETREE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AVP
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-228-2229
Mailing Address - Street 1:2705 E. PINETREE BLVD
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792-4875
Mailing Address - Country:US
Mailing Address - Phone:229-551-2365
Mailing Address - Fax:229-551-2397
Practice Address - Street 1:2705 E PINETREE BLVD
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-4875
Practice Address - Country:US
Practice Address - Phone:229-551-2365
Practice Address - Fax:229-551-2397
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JOHN D. ARCHBOLD MEMORIAL HOSPITAL, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-01-05
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0003X, 3336H0001X
GAPHRE0071223336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00420318AMedicaid
2020500OtherPK
GA00420318AMedicaid