Provider Demographics
NPI:1811902448
Name:MIDDLE FLINT COMMUNITY BOARD
Entity type:Organization
Organization Name:MIDDLE FLINT COMMUNITY BOARD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXEC DIR
Authorized Official - Prefix:
Authorized Official - First Name:PAM
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-931-2470
Mailing Address - Street 1:PO BOX 1348
Mailing Address - Street 2:
Mailing Address - City:AMERICUS
Mailing Address - State:GA
Mailing Address - Zip Code:31709-1348
Mailing Address - Country:US
Mailing Address - Phone:229-931-2474
Mailing Address - Fax:229-931-2474
Practice Address - Street 1:1335 N 5TH STREET EXT
Practice Address - Street 2:
Practice Address - City:CORDELE
Practice Address - State:GA
Practice Address - Zip Code:31015-3753
Practice Address - Country:US
Practice Address - Phone:229-276-2367
Practice Address - Fax:229-931-2474
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0063063336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA734807561BMedicaid
2015417OtherPK