Provider Demographics
NPI:1861505430
Name:DEPARTMENT OF BEHAVIORAL HEALTH AND DEVELOPMENTAL DISABILITIES
Entity Type:Organization
Organization Name:DEPARTMENT OF BEHAVIORAL HEALTH AND DEVELOPMENTAL DISABILITIES
Other - Org Name:CENTRAL STATE HOSPITAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGIONAL HOSPITAL ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:LATHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-445-4128
Mailing Address - Street 1:325 LAWRENCE RD
Mailing Address - Street 2:CENTRAL STATE HOSPITAL
Mailing Address - City:MILLEDGEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31062-7525
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:325 LAWRENCE RD
Practice Address - Street 2:CENTRAL STATE HOSPITAL
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31062-7525
Practice Address - Country:US
Practice Address - Phone:478-445-4041
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHH0064093336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00355704AMedicaid