Healthcare Provider Details

I. General information

NPI: 1477696722
Provider Name (Legal Business Name): J.H. HARVEYS CO.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 03/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12246 COLUMBIA ST STE F
BLAKELY GA
39823-2560
US

IV. Provider business mailing address

PO BOX 1000 MS3000
PORTLAND ME
04104-5005
US

V. Phone/Fax

Practice location:
  • Phone: 229-723-5202
  • Fax: 229-423-5221
Mailing address:
  • Phone: 207-885-7454
  • Fax: 207-396-2028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberPHRE012217
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHRE012217
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1155414
Identifier TypeOTHER
Identifier StateGA
Identifier IssuerNCPDP
# 2
Identifier501975150A
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer

VIII. Authorized Official

Name: COURTNEY FAIRBANKS
Title or Position: PHARMACY INSURANCE SPECIALIST
Credential:
Phone: 207-885-7454