Provider Demographics
NPI:1700925500
Name:J M BAILEY PHARMACY INC
Entity Type:Organization
Organization Name:J M BAILEY PHARMACY INC
Other - Org Name:FULCO DISCOUNT DRUGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRES OF CORP
Authorized Official - Prefix:
Authorized Official - First Name:JERRELL
Authorized Official - Middle Name:
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-384-7026
Mailing Address - Street 1:301 SHIRLEY AVE
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31533-2333
Mailing Address - Country:US
Mailing Address - Phone:912-384-7026
Mailing Address - Fax:912-384-9554
Practice Address - Street 1:301 SHIRLEY AVE
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-2333
Practice Address - Country:US
Practice Address - Phone:912-384-7026
Practice Address - Fax:912-384-9554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
GAPHRE0052483336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000160531AMedicaid
2014028OtherPK
2014028OtherPK