Provider Demographics
NPI:1710992326
Name:MILLEDGEVILLE MEDICAL CENTER PHARMACY INC
Entity Type:Organization
Organization Name:MILLEDGEVILLE MEDICAL CENTER PHARMACY INC
Other - Org Name:MEDICAL CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SEC
Authorized Official - Prefix:
Authorized Official - First Name:HJ
Authorized Official - Middle Name:
Authorized Official - Last Name:VINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-452-3591
Mailing Address - Street 1:750 N COBB ST
Mailing Address - Street 2:
Mailing Address - City:MILLEDGEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31061-2390
Mailing Address - Country:US
Mailing Address - Phone:478-452-3591
Mailing Address - Fax:478-452-3596
Practice Address - Street 1:750 N COBB ST
Practice Address - Street 2:
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-2390
Practice Address - Country:US
Practice Address - Phone:478-452-3591
Practice Address - Fax:478-452-3596
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
GAPHRE0036083336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2012676OtherPK
GA000032095AMedicaid
1048930002Medicare NSC