Provider Demographics
NPI:1730171513
Name:HARDIES DRUG STORE INC
Entity type:Organization
Organization Name:HARDIES DRUG STORE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRIDGES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-375-2545
Mailing Address - Street 1:38 S TALLAHASSEE ST
Mailing Address - Street 2:STE 1
Mailing Address - City:HAZLEHURST
Mailing Address - State:GA
Mailing Address - Zip Code:31539-6261
Mailing Address - Country:US
Mailing Address - Phone:912-375-2545
Mailing Address - Fax:912-375-0632
Practice Address - Street 1:38 S TALLAHASSEE ST
Practice Address - Street 2:STE 1
Practice Address - City:HAZLEHURST
Practice Address - State:GA
Practice Address - Zip Code:31539-6261
Practice Address - Country:US
Practice Address - Phone:912-375-2545
Practice Address - Fax:912-375-0632
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-18
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
GAPHRE0056563336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00545047AMedicaid
1110751OtherNCPDP PROVIDER IDENTIFICATION NUMBER
1110751OtherNCPDP PROVIDER IDENTIFICATION NUMBER