Provider Demographics
NPI:1821145319
Name:MAGNOLIA MANOR PHARMACY
Entity Type:Organization
Organization Name:MAGNOLIA MANOR PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:J
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:HILL
Authorized Official - Suffix:JR
Authorized Official - Credentials:RPH PHARMACIST
Authorized Official - Phone:478-783-1515
Mailing Address - Street 1:2001 SOUTH LEE ST
Mailing Address - Street 2:
Mailing Address - City:AMERICUS
Mailing Address - State:GA
Mailing Address - Zip Code:31709
Mailing Address - Country:US
Mailing Address - Phone:229-924-9352
Mailing Address - Fax:229-931-5956
Practice Address - Street 1:2001 S LEE ST
Practice Address - Street 2:
Practice Address - City:AMERICUS
Practice Address - State:GA
Practice Address - Zip Code:31709
Practice Address - Country:US
Practice Address - Phone:229-924-9352
Practice Address - Fax:229-931-5956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2008-04-16
Deactivation Date:2007-01-08
Deactivation Code:
Reactivation Date:2008-01-02
Provider Licenses
StateLicense IDTaxonomies
GA0022603336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1147950OtherNCPDP
GA00040785AMedicaid
1147950OtherOTHER ID NUMBER-COMMERCIAL NUMBER
GA1150040001Medicare NSC