Healthcare Provider Details

I. General information

NPI: 1649612789
Provider Name (Legal Business Name): EMILY KOUTROULAKIS PHARM.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2013
Last Update Date: 07/21/2020
Certification Date: 07/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2604 PEACH ORCHARD RD
AUGUSTA GA
30906-2489
US

IV. Provider business mailing address

2604 PEACH ORCHARD RD
AUGUSTA GA
30906-2489
US

V. Phone/Fax

Practice location:
  • Phone: 706-798-5645
  • Fax:
Mailing address:
  • Phone: 706-798-5645
  • Fax: 706-798-0377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number14218
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202212216
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH029652
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: