1447280672 NPI number — PINE MOUNTAIN PHARMACY, INC

Table of content: (NPI 1447280672)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447280672 NPI number — PINE MOUNTAIN PHARMACY, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PINE MOUNTAIN PHARMACY, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1447280672
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX A
Provider Second Line Business Mailing Address:
145 N MAIN AVE
Provider Business Mailing Address City Name:
PINE MOUNTAIN
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31822-0500
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-663-2255
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
145 N MAIN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PINE MOUNTAIN
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31822-0500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-663-2255
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/04/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
STOREY
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
IVERSON
Authorized Official Title or Position:
PRESIDENT OWNER
Authorized Official Telephone Number:
706-663-2255

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  158 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1112969 . This is a "NABP" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".