Provider Demographics
NPI:1023092624
Name:TY COBB HEALTHCARE SYSTEM LONG TERM CARE PHARMACY
Entity type:Organization
Organization Name:TY COBB HEALTHCARE SYSTEM LONG TERM CARE PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDONALD
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:706-245-1271
Mailing Address - Street 1:521 FRANKLIN SPRINGS ST
Mailing Address - Street 2:
Mailing Address - City:ROYSTON
Mailing Address - State:GA
Mailing Address - Zip Code:30662-3934
Mailing Address - Country:US
Mailing Address - Phone:706-245-1467
Mailing Address - Fax:706-245-1421
Practice Address - Street 1:521 FRANKLIN SPRINGS ST
Practice Address - Street 2:
Practice Address - City:ROYSTON
Practice Address - State:GA
Practice Address - Zip Code:30662-3934
Practice Address - Country:US
Practice Address - Phone:706-245-1467
Practice Address - Fax:706-245-1421
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-06
Last Update Date:2013-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0057183336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00059562BMedicaid
1126095OtherNCPDP PROVIDER IDENTIFICATION NUMBER