Provider Demographics
NPI:1710270814
Name:GEORGE COUNTY HOSPITAL
Entity Type:Organization
Organization Name:GEORGE COUNTY HOSPITAL
Other - Org Name:GEORGE COUNTY HOSPITAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DOP
Authorized Official - Prefix:
Authorized Official - First Name:CARMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-673-6181
Mailing Address - Street 1:859 WINTER ST
Mailing Address - Street 2:
Mailing Address - City:LUCEDALE
Mailing Address - State:MS
Mailing Address - Zip Code:39452-6603
Mailing Address - Country:US
Mailing Address - Phone:601-673-6181
Mailing Address - Fax:601-766-4293
Practice Address - Street 1:859 WINTER ST
Practice Address - Street 2:
Practice Address - City:LUCEDALE
Practice Address - State:MS
Practice Address - Zip Code:39452-6603
Practice Address - Country:US
Practice Address - Phone:601-673-6181
Practice Address - Fax:601-766-4293
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-23
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
MS02122/3.13336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2130446OtherPK