Provider Demographics
NPI:1558301069
Name:BLACKSHEAR DRUG CO
Entity Type:Organization
Organization Name:BLACKSHEAR DRUG CO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / PIC
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:CAREY
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:III
Authorized Official - Credentials:RPH
Authorized Official - Phone:912-449-6616
Mailing Address - Street 1:3487 US HIGHWAY 84
Mailing Address - Street 2:
Mailing Address - City:BLACKSHEAR
Mailing Address - State:GA
Mailing Address - Zip Code:31516-2293
Mailing Address - Country:US
Mailing Address - Phone:912-449-6616
Mailing Address - Fax:912-449-5759
Practice Address - Street 1:3487 US HIGHWAY 84
Practice Address - Street 2:
Practice Address - City:BLACKSHEAR
Practice Address - State:GA
Practice Address - Zip Code:31516-2293
Practice Address - Country:US
Practice Address - Phone:912-449-6616
Practice Address - Fax:912-449-5759
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0095093336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00035934CMedicaid
GA00035934AMedicaid
GA00035934AMedicaid
GA00035934CMedicaid