Provider Demographics
NPI:1477696722
Name:J.H. HARVEYS CO.
Entity Type:Organization
Organization Name:J.H. HARVEYS CO.
Other - Org Name:HARVEYS SUPERMARKET PHARMACY #2380
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY INSURANCE SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:FAIRBANKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-885-7454
Mailing Address - Street 1:PO BOX 1000
Mailing Address - Street 2:MS3000
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04104-5005
Mailing Address - Country:US
Mailing Address - Phone:207-885-7454
Mailing Address - Fax:207-396-2028
Practice Address - Street 1:12246 COLUMBIA ST STE F
Practice Address - Street 2:
Practice Address - City:BLAKELY
Practice Address - State:GA
Practice Address - Zip Code:39823-2560
Practice Address - Country:US
Practice Address - Phone:229-723-5202
Practice Address - Fax:229-423-5221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2011-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE012217332B00000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1155414OtherNCPDP
GA501975150AMedicaid
202G734361Medicare PIN
GA1155414OtherNCPDP