Provider Demographics
NPI:1528018413
Name:L M BASS LLC
Entity Type:Organization
Organization Name:L M BASS LLC
Other - Org Name:MAX BROWN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BLAKELY
Authorized Official - Middle Name:SUTTON
Authorized Official - Last Name:DENNARD
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:912-529-4545
Mailing Address - Street 1:794 SECOND STREET
Mailing Address - Street 2:
Mailing Address - City:SOPERTON
Mailing Address - State:GA
Mailing Address - Zip Code:30457
Mailing Address - Country:US
Mailing Address - Phone:912-529-4545
Mailing Address - Fax:912-529-6161
Practice Address - Street 1:809 N JEFFERSON STREET
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-6305
Practice Address - Country:US
Practice Address - Phone:478-272-8086
Practice Address - Fax:478-274-1171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000031413AMedicaid
1109405OtherNABP NUMBER
GA000031413AMedicaid