Provider Demographics
NPI:1831689728
Name:AUTRY STATE PRISON PHARMACY
Entity type:Organization
Organization Name:AUTRY STATE PRISON PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DEENA
Authorized Official - Middle Name:JONES
Authorized Official - Last Name:GAINOUS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:229-294-6786
Mailing Address - Street 1:PO BOX 648
Mailing Address - Street 2:
Mailing Address - City:PELHAM
Mailing Address - State:GA
Mailing Address - Zip Code:31779-0648
Mailing Address - Country:US
Mailing Address - Phone:229-294-6786
Mailing Address - Fax:229-294-6788
Practice Address - Street 1:3178 MOUNT ZION CHURCH RD
Practice Address - Street 2:
Practice Address - City:PELHAM
Practice Address - State:GA
Practice Address - Zip Code:31779
Practice Address - Country:US
Practice Address - Phone:229-294-6786
Practice Address - Fax:229-294-6788
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GEORGIA DEPARTMENT OF CORRECTIONS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-05-16
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHPR0074703336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy