Healthcare Provider Details

I. General information

NPI: 1285341503
Provider Name (Legal Business Name): TRI STAR DRUG AND ALCOHOL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2022
Last Update Date: 11/07/2022
Certification Date: 11/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N JEFFERSON ST UNIT C
DUBLIN GA
31021-6302
US

IV. Provider business mailing address

600 N JEFFERSON ST UNIT C
DUBLIN GA
31021-6302
US

V. Phone/Fax

Practice location:
  • Phone: 478-292-5755
  • Fax:
Mailing address:
  • Phone: 478-292-5755
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code332U00000X
TaxonomyHome Delivered Meals
License Number
License Number State

VIII. Authorized Official

Name: MR. JOHN WILLIAM GOOLSBY III
Title or Position: ADMIN
Credential:
Phone: 478-246-1027