Healthcare Provider Details

I. General information

NPI: 1285817742
Provider Name (Legal Business Name): LOVVORN PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2007
Last Update Date: 02/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 TALLAPOOSA ST
BREMEN GA
30110
US

IV. Provider business mailing address

240 TALLAPOOSA ST
BREMEN GA
30110
US

V. Phone/Fax

Practice location:
  • Phone: 770-537-2386
  • Fax: 770-537-4418
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHRE000156
License Number StateGA

VIII. Authorized Official

Name: WILLIAM LOVVORN
Title or Position: OWNER
Credential: RPH
Phone: 770-537-2386