Provider Demographics
NPI:1982733267
Name:SCOTT AND MARY HARTZOG, LLC
Entity Type:Organization
Organization Name:SCOTT AND MARY HARTZOG, LLC
Other - Org Name:SEMINOLE HARTZOG PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:HARTZOG
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:229-524-2223
Mailing Address - Street 1:PO BOX 337
Mailing Address - Street 2:
Mailing Address - City:DONALSONVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:39845-0337
Mailing Address - Country:US
Mailing Address - Phone:229-524-5364
Mailing Address - Fax:229-524-8798
Practice Address - Street 1:111 E 2ND ST
Practice Address - Street 2:
Practice Address - City:DONALSONVILLE
Practice Address - State:GA
Practice Address - Zip Code:39845-1601
Practice Address - Country:US
Practice Address - Phone:229-524-5364
Practice Address - Fax:229-524-8798
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2022-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0091283336C0003X, 3336C0003X
GA818850627B332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000035681AMedicaid
GA818850627BMedicaid
1109227OtherNABP
GA818850627BMedicaid