Provider Demographics
NPI:1801881545
Name:MIDDLE MOODYCARE INC
Entity type:Organization
Organization Name:MIDDLE MOODYCARE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:BENJAMIN
Authorized Official - Last Name:MOODY
Authorized Official - Suffix:III
Authorized Official - Credentials:RPH
Authorized Official - Phone:478-781-1213
Mailing Address - Street 1:4839 BLOOMFIELD RD
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31206-4307
Mailing Address - Country:US
Mailing Address - Phone:478-781-1213
Mailing Address - Fax:478-788-9078
Practice Address - Street 1:4839 BLOOMFIELD RD
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31206-4307
Practice Address - Country:US
Practice Address - Phone:478-781-1213
Practice Address - Fax:478-788-9078
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-19
Last Update Date:2025-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE006040333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1111828OtherNCPDP
GA000033448COtherMEDICAID DME
GA000033448AMedicaid
1111828OtherNCPDP