Healthcare Provider Details

I. General information

NPI: 1851032692
Provider Name (Legal Business Name): PRIMARY CARE OF SOUTHWEST GEORGIA, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 07/21/2022
Certification Date: 07/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

454 SMITH AVE
THOMASVILLE GA
31792-5535
US

IV. Provider business mailing address

454 SMITH AVE
THOMASVILLE GA
31792-5535
US

V. Phone/Fax

Practice location:
  • Phone: 229-516-8877
  • Fax: 833-530-1910
Mailing address:
  • Phone: 229-227-5510
  • Fax: 229-227-5527

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: EDWIN JAMES
Title or Position: CFO
Credential:
Phone: 229-723-2660