Provider Demographics
NPI:1609263631
Name:EAST GA SPECIALTY PHARMACY
Entity Type:Organization
Organization Name:EAST GA SPECIALTY PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:AIMAR
Authorized Official - Last Name:GOODWIN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH MS
Authorized Official - Phone:912-655-9080
Mailing Address - Street 1:400 E GRADY ST
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-5157
Mailing Address - Country:US
Mailing Address - Phone:912-655-9080
Mailing Address - Fax:
Practice Address - Street 1:400 E GRADY ST
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-5157
Practice Address - Country:US
Practice Address - Phone:912-655-9080
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-16
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy