Provider Demographics
NPI:1043301872
Name:PIONEER HEALTH SERVICES OF EARLY COUNTY LLC
Entity type:Organization
Organization Name:PIONEER HEALTH SERVICES OF EARLY COUNTY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIR OF PHCY
Authorized Official - Prefix:
Authorized Official - First Name:WADE
Authorized Official - Middle Name:
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-724-4208
Mailing Address - Street 1:11740 COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:BLAKELY
Mailing Address - State:GA
Mailing Address - Zip Code:39823-2574
Mailing Address - Country:US
Mailing Address - Phone:229-724-4208
Mailing Address - Fax:229-724-4268
Practice Address - Street 1:11740 COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:BLAKELY
Practice Address - State:GA
Practice Address - Zip Code:39823-2574
Practice Address - Country:US
Practice Address - Phone:229-724-4208
Practice Address - Fax:229-724-4268
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2015-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE096913336C0003X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2127003OtherPK
GA000000635AMedicaid