HOSPITAL PHARMACY OF MOULTRIE INC (CONVENIENT CARE PHARMACY #1) - NPI NUMBER 1558427468

Summary

Provider Name: HOSPITAL PHARMACY OF MOULTRIE INC (CONVENIENT CARE PHARMACY #1)

NPI Number: 1558427468

Clasification: Pharmacy (3336C0003X)

Specialization: Community/Retail Pharmacy

Address:
203 31ST AVE SE
MOULTRIE, GA
ZIP 31768

Phone Number: (229) 985-9296



Detailed Information

HOSPITAL PHARMACY OF MOULTRIE INC is a community/retail pharmacy pharmacy in Moultrie, GA. The provider is a pharmacy where pharmacists store, prepare, and dispense medicinal preparations and/or prescriptions for a local patient population in accordance with federal and state law; counsel patients and caregivers (sometimes independent of the dispensing process); administer vaccinations; and provide other professional services associated with pharmaceutical care such as health screenings, consultative services with other health care providers, collaborative practice, disease state management, and education classes. The assigned NPI number for this provider is 1558427468 and is registered as an organization entity type.
The provider Is Doing Business As Convenient Care Pharmacy #1.

The provider's business address is:

203 31ST AVE SE
MOULTRIE, GA
ZIP 31768-703
Phone: (229) 985-9296
Fax: (229) 985-3771

The provider's authorized official is Gregory L Yarbrough .
The authorized official title is President and has the following contact phone number (229) 985-9296.

The enumeration date for this NPI number is 12/28/2006 and was last updated on 9/24/2013.

Map - Location of Practice

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Taxonomy Codes

The following information regarding the scope of practice of this provider is available:

No. Taxonomy Code Taxonomy Clasification Taxonomy Specialization License Number License State Primary
1 3336C0003X Pharmacy Community/Retail Pharmacy 4738 GA Yes

Other (Legacy) Identifiers

The following legacy identifiers are available for this provider:

No. Other Provider Identifier Other Provider Identifier Type Other Provider Identifier State Other Provider Identifier Issuer
1 1225350001 MEDICARE NSC
2 1116981 OTHER NCPDP #
3 00069858A MEDICAID GA

NPI Record

No. Field Name Field Value Field Definition 1
1 NPI 1558427468 The 10-position all-numeric identification number assigned by the NPS to uniquely identify a health care provider. The NPI number includes an ISO standard check-digit in the 10th position. There is no intelligence about the health care provider in the number.
2 Entity Type Code 2 Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO).
3 Employer Identification Number EIN The Employer Identification Number (EIN), assigned by the IRS, of the provider being identified.
4 Provider Organization Name Legal Business Name HOSPITAL PHARMACY OF MOULTRIE INC The name of the organization provider. If the provider is an organization, this is the legal business name.
5 Provider Other Organization Name CONVENIENT CARE PHARMACY #1 Other name by which the organization provider is or has been known.
6 Provider Other Organization Name Type Code 3 Code identifying the type of other name. Codes are: 1 = former name; 2 = professional name; 3 = doing business as (d/b/ a) name; 4 = former legal business name; 5 = other.
7 Provider First Line Business Practice Location Address 203 31ST AVE SE The first line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
8 Provider Business Practice Location Address City Name MOULTRIE The city name in the location address of the provider being identified.
9 Provider Business Practice Location Address State Name GA The State code in the location of the provider being identified.
10 Provider Business Practice Location Address Postal Code 317686703 The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available.
11 Provider Business Practice Location Address Country Code If outside U S US The country code in the location address of the provider being identified.
12 Provider Business Practice Location Address Telephone Number 2299859296 The telephone number associated with the location address of the provider being identified.
13 Provider Business Practice Location Address Fax Number 2299853771 The fax number associated with the location address of the provider being identified.
14 Provider Enumeration Date 12/28/2006 The date the provider was assigned a unique identifier (assigned an NPI).
15 Last Update Date 9/24/2013 The date that a record was last updated or changed.
16 Authorized Official Last Name YARBROUGH The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider.
17 Authorized Official First Name GREGORY The first name of the authorized official.
18 Authorized Official Middle Name L The middle name of the authorized official.
19 Authorized Official Title or Position PRESIDENT The title or position of the authorized official.
20 Authorized Official Telephone Number 2299859296 The 10-position telephone number of the authorized official.
21 Healthcare Provider Taxonomy Code 1 3336C0003X Code designating the provider type, classification, and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1.
22 Provider License Number 1 4738 The license number issued to the provider being identified. The NPS can accommodate multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’.
23 Provider License Number State Code 1 GA The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number.
24 Healthcare Provider Primary Taxonomy Switch 1 Y
25 Other Provider Identifier 1 1225350001 Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form.
26 Other Provider Identifier Type Code 1 07 Code indicating the type of identifier currently or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form.
27 Other Provider Identifier 2 1116981 Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form.
28 Other Provider Identifier Type Code 2 01 Code indicating the type of identifier currently or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form.
29 Other Provider Identifier Issuer 2 NCPDP #
30 Other Provider Identifier 3 00069858A Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form.
31 Other Provider Identifier Type Code 3 05 Code indicating the type of identifier currently or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form.
32 Other Provider Identifier State 3 GA
33 Is Organization Subpart N
34 Authorized Official Credential Text R.PH.

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This page was last updated on: 3/10/2015

(1) Field Definition Source-. Federal Register / Vol. 69, No. 15 / Friday, January 23, 2004 / Rules and Regulations - Part II Department of Health and Human Services Office of the Secretary 45 CFR Part 162 HIPAA Administrative Simplification: Standard Unique Health Identifier for Health Care Providers; Final Rule

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