1104934579 NPI number — J.H. HARVEY CO., LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104934579 NPI number — J.H. HARVEY CO., LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
J.H. HARVEY CO., LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
HARVEYS SUPERMARKET PHARMACY #2398
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104934579
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/15/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1000
Provider Second Line Business Mailing Address:
MS3000
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04104-5005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-885-7454
Provider Business Mailing Address Fax Number:
207-396-2028

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
107 PRINCE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AMERICUS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31709-3643
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
229-931-6312
Provider Business Practice Location Address Fax Number:
229-931-9359
Provider Enumeration Date:
08/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FAIRBANKS
Authorized Official First Name:
COURTNEY
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACY INSURANCE SPECIALIST
Authorized Official Telephone Number:
207-885-7454

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  PHRE008270 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1145754 . This is a "NCPDP" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 00810598A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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