Healthcare Provider Details

I. General information

NPI: 1790077170
Provider Name (Legal Business Name): LORELEI MERCEDES CHARTERS RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2011
Last Update Date: 05/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 W HWY 80
GARDEN CITY GA
31408-3108
US

IV. Provider business mailing address

PO BOX 7709
GARDEN CITY GA
31418-7709
US

V. Phone/Fax

Practice location:
  • Phone: 912-966-1416
  • Fax: 912-966-1417
Mailing address:
  • Phone: 912-966-1416
  • Fax: 912-966-1417

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number016448
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: