Provider Demographics
NPI:1598721086
Name:MEDICAL CENTER PRESCRIPTION SHOP
Entity Type:Organization
Organization Name:MEDICAL CENTER PRESCRIPTION SHOP
Other - Org Name:PRESCRIPTION SHOP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:FREDERICK
Authorized Official - Last Name:DWOZAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:478-374-5514
Mailing Address - Street 1:710 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:EASTMAN
Mailing Address - State:GA
Mailing Address - Zip Code:31023
Mailing Address - Country:US
Mailing Address - Phone:478-374-5514
Mailing Address - Fax:478-374-8617
Practice Address - Street 1:710 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:EASTMAN
Practice Address - State:GA
Practice Address - Zip Code:31023
Practice Address - Country:US
Practice Address - Phone:478-374-5514
Practice Address - Fax:478-374-8617
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-24
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE006118333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00031864AMedicaid