Provider Demographics
NPI:1902397151
Name:AUGUSTA STATE MEDICAL PRISON
Entity Type:Organization
Organization Name:AUGUSTA STATE MEDICAL PRISON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ELAINE
Authorized Official - Middle Name:
Authorized Official - Last Name:REIFINGER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:706-855-4789
Mailing Address - Street 1:3001 GORDON HWY
Mailing Address - Street 2:
Mailing Address - City:GROVETOWN
Mailing Address - State:GA
Mailing Address - Zip Code:30813-3808
Mailing Address - Country:US
Mailing Address - Phone:706-855-4744
Mailing Address - Fax:706-869-7990
Practice Address - Street 1:3001 GORDON HWY
Practice Address - Street 2:
Practice Address - City:GROVETOWN
Practice Address - State:GA
Practice Address - Zip Code:30813-3808
Practice Address - Country:US
Practice Address - Phone:706-855-4744
Practice Address - Fax:706-869-7990
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
GAPHH0060833336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy