MEDICARE: TY COBB HEALTHCARE SYSTEM LONG TERM CARE PHARMACY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336L0003X	Long Term Care Pharmacy	PHRE005718	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	1126095	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1023092624
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TY COBB HEALTHCARE SYSTEM LONG TERM CARE PHARMACY

Provider Business Mailing Address
First Line	:	521 FRANKLIN SPRINGS ST
Second Line	:
City	:	ROYSTON
State	:	GA
Zip	:	30662-3934
Country	:	US
Telephone Number	:	706-245-1467
Fax Number	:	706-245-1421

Provider Business Practice Location Address
First Line	:	521 FRANKLIN SPRINGS ST
Second Line	:
City	:	ROYSTON
State	:	GA
Zip	:	30662-3934
Country	:	US
Telephone Number	:	706-245-1467
Fax Number	:	706-245-1421

Authorized Official
Title or Position	:	DIRECTOR
Name	:	JESSICA MCDONALD
Credential	:	PHARM.D.
Telephone Number	:	706-245-1271

Provider Enumeration Date	:	12/06/2005
Last Update Date	:	01/25/2013

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Directions to “TY COBB HEALTHCARE SYSTEM LONG TERM CARE PHARMACY ” Practice Location

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