Healthcare Provider Details

I. General information

NPI: 1316976467
Provider Name (Legal Business Name): CAMILLA PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2006
Last Update Date: 01/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

92 E BROAD ST
CAMILLA GA
31730-1832
US

IV. Provider business mailing address

PO BOX 33
CAMILLA GA
31730-0033
US

V. Phone/Fax

Practice location:
  • Phone: 229-336-8474
  • Fax: 229-336-5602
Mailing address:
  • Phone: 229-336-8474
  • Fax: 229-336-5602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPHRE003289
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberPHRE003289
License Number StateGA

VIII. Authorized Official

Name: MR. LEN F REYNOLDS
Title or Position: PRESIDENT
Credential: R.PH.
Phone: 229-336-8474