Provider Demographics
NPI:1982776845
Name:J. H. HARVEY, CO., LLC
Entity Type:Organization
Organization Name:J. H. HARVEY, CO., LLC
Other - Org Name:HARVEYS SUPERMARKET PHARMACY #2365
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY INSURANCE SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:FAIRBANKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-885-7454
Mailing Address - Street 1:PO BOX 1000
Mailing Address - Street 2:MS3000
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04104-5005
Mailing Address - Country:US
Mailing Address - Phone:207-885-7454
Mailing Address - Fax:207-396-2028
Practice Address - Street 1:955 S 1ST ST
Practice Address - Street 2:
Practice Address - City:JESUP
Practice Address - State:GA
Practice Address - Zip Code:31545-0331
Practice Address - Country:US
Practice Address - Phone:912-427-6239
Practice Address - Fax:912-427-6295
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2011-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
GAPHRE0090983336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA019754197AMedicaid
1155161OtherNCPDP NUMBER
1155161OtherNCPDP NUMBER
GA019754197AMedicaid