Provider Demographics
NPI:1851882013
Name:LEE ARRENDALE STATE PRISON PHARMACY
Entity Type:Organization
Organization Name:LEE ARRENDALE STATE PRISON PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TOM
Authorized Official - Middle Name:
Authorized Official - Last Name:POOLE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:706-776-0661
Mailing Address - Street 1:PO BOX 709
Mailing Address - Street 2:
Mailing Address - City:ALTO
Mailing Address - State:GA
Mailing Address - Zip Code:30510-0709
Mailing Address - Country:US
Mailing Address - Phone:706-776-0661
Mailing Address - Fax:706-776-4982
Practice Address - Street 1:2023A GAINESVILLE HWY
Practice Address - Street 2:
Practice Address - City:ALTO
Practice Address - State:GA
Practice Address - Zip Code:30510-4435
Practice Address - Country:US
Practice Address - Phone:706-776-0661
Practice Address - Fax:706-776-4982
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GEORGIA DEPARTMENT OF CORRECTIONS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-05-23
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHPR0061573336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy