Provider Demographics
NPI:1760618557
Name:MACON ORTHOPEDIC & HAND CENTER PA
Entity Type:Organization
Organization Name:MACON ORTHOPEDIC & HAND CENTER PA
Other - Org Name:ORTHO GA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:BS PHARMACY
Authorized Official - Phone:478-750-2802
Mailing Address - Street 1:3708 NORTHSIDE DR
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-2404
Mailing Address - Country:US
Mailing Address - Phone:478-750-2802
Mailing Address - Fax:478-254-5460
Practice Address - Street 1:3708 NORTHSIDE DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-2404
Practice Address - Country:US
Practice Address - Phone:478-750-2802
Practice Address - Fax:478-254-5460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-07
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
GAPHRE0095813336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2120271OtherPK
GA975178315AMedicaid
GA975178315AMedicaid