Provider Demographics
NPI:1730121351
Name:CALDWELL CORP OF THOMASTON INC
Entity Type:Organization
Organization Name:CALDWELL CORP OF THOMASTON INC
Other - Org Name:CHEROKEE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:CALDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:706-646-3100
Mailing Address - Street 1:200 CHEROKEE RD
Mailing Address - Street 2:
Mailing Address - City:THOMASTON
Mailing Address - State:GA
Mailing Address - Zip Code:30286-3402
Mailing Address - Country:US
Mailing Address - Phone:706-646-3100
Mailing Address - Fax:706-646-3111
Practice Address - Street 1:200 CHEROKEE RD
Practice Address - Street 2:
Practice Address - City:THOMASTON
Practice Address - State:GA
Practice Address - Zip Code:30286-3402
Practice Address - Country:US
Practice Address - Phone:706-646-3100
Practice Address - Fax:706-646-3111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2014-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
GAPHRE0078583336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2019133OtherPK
GA00655828AMedicaid
2019133OtherPK