Provider Demographics
NPI:1972666576
Name:BACON COUNTY HEALTH SVC INC
Entity Type:Organization
Organization Name:BACON COUNTY HEALTH SVC INC
Other - Org Name:BACON COUNTY HOSPITAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIR OF PHRM SRV
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:LOTT
Authorized Official - Suffix:
Authorized Official - Credentials:PHRMD
Authorized Official - Phone:912-632-8961
Mailing Address - Street 1:302 S WAYNE ST
Mailing Address - Street 2:PO DRAWER 1987
Mailing Address - City:ALMA
Mailing Address - State:GA
Mailing Address - Zip Code:31510-2922
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:302 S WAYNE ST
Practice Address - Street 2:
Practice Address - City:ALMA
Practice Address - State:GA
Practice Address - Zip Code:31510-2922
Practice Address - Country:US
Practice Address - Phone:912-632-8961
Practice Address - Fax:912-632-2231
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336I0012X
GA80863336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00000118BMedicaid
2013239OtherPK