Healthcare Provider Details

I. General information

NPI: 1043301872
Provider Name (Legal Business Name): PIONEER HEALTH SERVICES OF EARLY COUNTY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 07/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11740 COLUMBIA ST
BLAKELY GA
39823-2574
US

IV. Provider business mailing address

11740 COLUMBIA ST
BLAKELY GA
39823-2574
US

V. Phone/Fax

Practice location:
  • Phone: 229-724-4208
  • Fax: 229-724-4268
Mailing address:
  • Phone: 229-724-4208
  • Fax: 229-724-4268

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHRE09691
License Number StateGA

VIII. Authorized Official

Name: WADE COOK
Title or Position: DIR OF PHCY
Credential:
Phone: 229-724-4208