Provider Demographics
NPI:1548260144
Name:DEKALB COMMUNITY SERVICE BOARD
Entity type:Organization
Organization Name:DEKALB COMMUNITY SERVICE BOARD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:S
Authorized Official - Last Name:RICHEY
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:404-294-3836
Mailing Address - Street 1:3807 CLAIRMONT RD
Mailing Address - Street 2:
Mailing Address - City:CHAMBLEE
Mailing Address - State:GA
Mailing Address - Zip Code:30341-4911
Mailing Address - Country:US
Mailing Address - Phone:770-457-6236
Mailing Address - Fax:
Practice Address - Street 1:3807 CLAIRMONT RD
Practice Address - Street 2:
Practice Address - City:CHAMBLEE
Practice Address - State:GA
Practice Address - Zip Code:30341-4911
Practice Address - Country:US
Practice Address - Phone:770-457-6236
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA007051183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00058858AMedicaid
GA1136654OtherNCPDP/NABP PROVIDER NUMBE