Healthcare Provider Details

I. General information

NPI: 1164596680
Provider Name (Legal Business Name): COLBERT PHARMACY INC 127 4TH ST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 06/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5674 HIGHWAY 72 W
COLBERT GA
30628-2934
US

IV. Provider business mailing address

PO BOX 336
COLBERT GA
30628-0336
US

V. Phone/Fax

Practice location:
  • Phone: 706-788-2102
  • Fax: 706-788-9740
Mailing address:
  • Phone: 706-788-2102
  • Fax: 706-788-9470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHRE004838
License Number StateGA

VIII. Authorized Official

Name: WALTER WHITE
Title or Position: PRES
Credential: RPH
Phone: 706-788-2102