Provider Demographics
NPI:1982928834
Name:SOUTHWEST GEORGIA COMPOUNDING PHARMACY
Entity Type:Organization
Organization Name:SOUTHWEST GEORGIA COMPOUNDING PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOE HARRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:MORGAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:229-336-9334
Mailing Address - Street 1:181 E BROAD ST
Mailing Address - Street 2:P.O. BOX 66
Mailing Address - City:CAMILLA
Mailing Address - State:GA
Mailing Address - Zip Code:31730-1966
Mailing Address - Country:US
Mailing Address - Phone:229-336-9334
Mailing Address - Fax:229-336-9525
Practice Address - Street 1:181 E BROAD ST
Practice Address - Street 2:
Practice Address - City:CAMILLA
Practice Address - State:GA
Practice Address - Zip Code:31730-1966
Practice Address - Country:US
Practice Address - Phone:229-336-9334
Practice Address - Fax:229-336-9525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-22
Last Update Date:2010-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0096383336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA009638OtherPHARMACY STATE LISCENSE NUMBER