Provider Demographics
NPI:1932684032
Name:MEDCTR INC
Entity Type:Organization
Organization Name:MEDCTR INC
Other - Org Name:HARLEM PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:W
Authorized Official - Last Name:PULLIAM
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:706-396-3900
Mailing Address - Street 1:170 W.MILLLEDGEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:HARLEM
Mailing Address - State:GA
Mailing Address - Zip Code:30814-5125
Mailing Address - Country:US
Mailing Address - Phone:706-396-3900
Mailing Address - Fax:706-396-3910
Practice Address - Street 1:170 W MILLEDGEVILLE RD
Practice Address - Street 2:
Practice Address - City:HARLEM
Practice Address - State:GA
Practice Address - Zip Code:30814-5125
Practice Address - Country:US
Practice Address - Phone:706-513-2424
Practice Address - Fax:706-396-3910
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEDCTR INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-09-25
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003221093AMedicaid