Healthcare Provider Details

I. General information

NPI: 1740270099
Provider Name (Legal Business Name): MOULTRIE PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2005
Last Update Date: 03/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3690 US HIGHWAY 1 S
ST AUGUSTINE FL
32086-6498
US

IV. Provider business mailing address

3690 US HIGHWAY 1 S
ST AUGUSTINE FL
32086-6498
US

V. Phone/Fax

Practice location:
  • Phone: 904-794-1399
  • Fax: 904-794-1193
Mailing address:
  • Phone: 904-794-1399
  • Fax: 904-794-1193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPH19146
License Number StateFL

VIII. Authorized Official

Name: DELAINE MCCARTY
Title or Position: OWNER
Credential:
Phone: 904-794-1399