Provider Demographics
NPI:1740585934
Name:J.H. HARVEY CO., LLC
Entity Type:Organization
Organization Name:J.H. HARVEY CO., LLC
Other - Org Name:HARVEYS SUPERMARKET PHARMACY #2406
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY INSURANCE SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:FAIRBANKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-885-7454
Mailing Address - Street 1:PO BOX 1000
Mailing Address - Street 2:MAILSORT 3000
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04104-5005
Mailing Address - Country:US
Mailing Address - Phone:207-885-7454
Mailing Address - Fax:207-396-2028
Practice Address - Street 1:775 GA HWY 122 W
Practice Address - Street 2:
Practice Address - City:HAHIRA
Practice Address - State:GA
Practice Address - Zip Code:31632
Practice Address - Country:US
Practice Address - Phone:229-794-2989
Practice Address - Fax:229-794-0089
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-19
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003106841AMedicaid
1160946OtherNCPDP PROVIDER NUMBER
GA003106841AMedicaid