MEDICARE: EAST GEORGIA PREVENTATIVE HEALTH SPECIALISTS, LLC

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	3336C0004X	Compounding Pharmacy	PHRE008829	GA

General Provider Information

NPI Number	:	1790908622
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST GEORGIA PREVENTATIVE HEALTH SPECIALISTS, LLC

Provider Business Mailing Address
First Line	:	150 S LEROY ST STE A
Second Line	:
City	:	METTER
State	:	GA
Zip	:	30439-4631
Country	:	US
Telephone Number	:	912-685-7498
Fax Number	:	912-685-3777

Provider Business Practice Location Address
First Line	:	150 S LEROY ST STE A
Second Line	:
City	:	METTER
State	:	GA
Zip	:	30439-4631
Country	:	US
Telephone Number	:	912-685-7498
Fax Number	:	912-685-3777

Authorized Official
Title or Position	:	OWNER
Name	:	MR. BOBBY DEAN STONE JR.
Credential	:	RPH, CDM
Telephone Number	:	912-685-7498

Provider Enumeration Date	:	04/10/2007
Last Update Date	:	08/22/2020

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