Provider Demographics
NPI:1730124587
Name:MCRAES PHARMACY OF DOUGLAS INC
Entity Type:Organization
Organization Name:MCRAES PHARMACY OF DOUGLAS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHAR-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:HOLT
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:912-384-5255
Mailing Address - Street 1:1002 WARD ST W
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31533-2251
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1002 WARD ST W
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-2251
Practice Address - Country:US
Practice Address - Phone:912-384-5255
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH028222183500000X
GAPHRE0033653336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000031622AMedicaid