Healthcare Provider Details

I. General information

NPI: 1043440894
Provider Name (Legal Business Name): PRETTY IN PINK BOUTIQUE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2009
Last Update Date: 09/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 S JEFFERSON AVE
EATONTON GA
31024-1023
US

IV. Provider business mailing address

111 S JEFFERSON AVE
EATONTON GA
31024-1023
US

V. Phone/Fax

Practice location:
  • Phone: 706-485-4774
  • Fax:
Mailing address:
  • Phone: 706-485-4774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: MRS. CHRISTY H THIGPEN
Title or Position: OWNER/MANAGER
Credential:
Phone: 706-485-4774