Provider Demographics
NPI:1841334323
Name:I.V. CARE OF EAST GEORGIA, INC.
Entity type:Organization
Organization Name:I.V. CARE OF EAST GEORGIA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HAROLD
Authorized Official - Middle Name:M
Authorized Official - Last Name:KEMP
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:912-739-0673
Mailing Address - Street 1:PO BOX 830
Mailing Address - Street 2:
Mailing Address - City:CLAXTON
Mailing Address - State:GA
Mailing Address - Zip Code:30417-0830
Mailing Address - Country:US
Mailing Address - Phone:912-739-0673
Mailing Address - Fax:
Practice Address - Street 1:107 S DUVAL ST
Practice Address - Street 2:B
Practice Address - City:CLAXTON
Practice Address - State:GA
Practice Address - Zip Code:30417-2029
Practice Address - Country:US
Practice Address - Phone:912-739-0673
Practice Address - Fax:912-739-1125
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0071743336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00455925AMedicaid
GA00455925AMedicaid