Provider Demographics
NPI:1598326027
Name:MIDDLE CREEK MANAGEMENT
Entity Type:Organization
Organization Name:MIDDLE CREEK MANAGEMENT
Other - Org Name:ASHBURN FAMILY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PIC
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:DUNN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:229-392-6328
Mailing Address - Street 1:123 E COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:ASHBURN
Mailing Address - State:GA
Mailing Address - Zip Code:31714-5203
Mailing Address - Country:US
Mailing Address - Phone:229-778-9889
Mailing Address - Fax:229-778-9892
Practice Address - Street 1:123 E COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:ASHBURN
Practice Address - State:GA
Practice Address - Zip Code:31714-5203
Practice Address - Country:US
Practice Address - Phone:229-778-9889
Practice Address - Fax:229-778-9892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-25
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003221324AMedicaid