Provider Demographics
NPI:1770865248
Name:PAULDING MEDICAL CENTER
Entity Type:Organization
Organization Name:PAULDING MEDICAL CENTER
Other - Org Name:WELLSTAR PHARMACY NETWORK STORE #4
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SITE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:T. MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:HANEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-445-4411
Mailing Address - Street 1:WELLSTAR PAULDING HOSPITAL
Mailing Address - Street 2:600 W. MEMORIAL DRIVE
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30132
Mailing Address - Country:US
Mailing Address - Phone:770-443-4780
Mailing Address - Fax:770-443-4782
Practice Address - Street 1:600 W MEMORIAL DR
Practice Address - Street 2:WELLSTAR PAULDING HOSPITAL
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30132-4117
Practice Address - Country:US
Practice Address - Phone:770-443-4780
Practice Address - Fax:770-443-4782
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-12
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0097643336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000001438BMedicaid
1161722OtherNCPDP PROVIDER IDENTIFICATION NUMBER
1161722OtherNCPDP PROVIDER IDENTIFICATION NUMBER