Provider Demographics
NPI:1952351629
Name:CAMDEN PHARMACY INC
Entity type:Organization
Organization Name:CAMDEN PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:KICKLIGHTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-673-8220
Mailing Address - Street 1:214 PROFESSIONAL CIR STE B
Mailing Address - Street 2:
Mailing Address - City:SAINT MARYS
Mailing Address - State:GA
Mailing Address - Zip Code:31558-3783
Mailing Address - Country:US
Mailing Address - Phone:912-673-8220
Mailing Address - Fax:912-673-7035
Practice Address - Street 1:214 PROFESSIONAL CIR STE B
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:GA
Practice Address - Zip Code:31558-3783
Practice Address - Country:US
Practice Address - Phone:912-673-8220
Practice Address - Fax:912-673-7035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2020-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0004X, 3336L0003X, 3336C0004X
GAPHRE0090193336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2016284OtherPK
GA455711609AMedicaid
GA455711609AMedicaid