Healthcare Provider Details

I. General information

NPI: 1770426504
Provider Name (Legal Business Name): PMR RETAILER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2026
Last Update Date: 04/14/2026
Certification Date: 04/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13 RAY RD
COVINGTON GA
30014-5954
US

IV. Provider business mailing address

13 RAY RD
COVINGTON GA
30014-5954
US

V. Phone/Fax

Practice location:
  • Phone: 470-205-9882
  • Fax:
Mailing address:
  • Phone: 470-205-9882
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251X00000X
TaxonomySupports Brokerage Agency
License Number
License Number State

VIII. Authorized Official

Name: PAMELA MECHELLE RUSSELL
Title or Position: OWNER
Credential: AAS, OVC/NOVA
Phone: 470-205-9882