Healthcare Provider Details

I. General information

NPI: 1811700677
Provider Name (Legal Business Name): MEDSTORE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2025
Last Update Date: 01/27/2025
Certification Date: 01/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 DAVIS RD STE C
AUGUSTA GA
30907-0954
US

IV. Provider business mailing address

1940 LAKEWOOD TER SE
ATLANTA GA
30315-6669
US

V. Phone/Fax

Practice location:
  • Phone: 404-333-2968
  • Fax:
Mailing address:
  • Phone: 818-791-6725
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QV0200X
TaxonomyVA Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: NEHEMIAH TRAVIS HARVARD
Title or Position: CEO
Credential:
Phone: 404-333-2968