Healthcare Provider Details

I. General information

NPI: 1851882013
Provider Name (Legal Business Name): LEE ARRENDALE STATE PRISON PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2018
Last Update Date: 05/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2023A GAINESVILLE HWY
ALTO GA
30510-4435
US

IV. Provider business mailing address

PO BOX 709
ALTO GA
30510-0709
US

V. Phone/Fax

Practice location:
  • Phone: 706-776-0661
  • Fax: 706-776-4982
Mailing address:
  • Phone: 706-776-0661
  • Fax: 706-776-4982

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336I0012X
TaxonomyInstitutional Pharmacy
License NumberPHPR006157
License Number StateGA

VIII. Authorized Official

Name: TOM POOLE
Title or Position: PHARMACY DIRECTOR
Credential: RPH
Phone: 706-776-0661