Provider Demographics
NPI:1902397995
Name:PULASKI STATE PRISON REGIONAL PHARMACY
Entity Type:Organization
Organization Name:PULASKI STATE PRISON REGIONAL PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODROE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:478-783-6097
Mailing Address - Street 1:373 UPPER RIVER RD
Mailing Address - Street 2:
Mailing Address - City:HAWKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31036-8898
Mailing Address - Country:US
Mailing Address - Phone:478-783-6097
Mailing Address - Fax:478-783-6252
Practice Address - Street 1:373 UPPER RIVER RD
Practice Address - Street 2:
Practice Address - City:HAWKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:31036-8898
Practice Address - Country:US
Practice Address - Phone:478-783-6097
Practice Address - Fax:478-783-6252
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GEORGIA DEPARTMENT OF CORRECTIONS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-05-24
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHPR0077923336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy