Healthcare Provider Details

I. General information

NPI: 1154038909
Provider Name (Legal Business Name): PINEAPPLE PATHWAY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2022
Last Update Date: 11/01/2022
Certification Date: 11/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 WESTBROOK RD
DOTHAN AL
36303-2971
US

IV. Provider business mailing address

400 WESTBROOK RD
DOTHAN AL
36303-2971
US

V. Phone/Fax

Practice location:
  • Phone: 904-451-7689
  • Fax:
Mailing address:
  • Phone: 904-451-7689
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: GRADY MURRAY
Title or Position: CEO
Credential: MS, RDN, LDN
Phone: 904-451-7689