Healthcare Provider Details

I. General information

NPI: 1932684032
Provider Name (Legal Business Name): MEDCTR INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2018
Last Update Date: 01/26/2024
Certification Date: 01/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 W MILLEDGEVILLE RD
HARLEM GA
30814-5125
US

IV. Provider business mailing address

170 W.MILLLEDGEVILLE RD
HARLEM GA
30814-5125
US

V. Phone/Fax

Practice location:
  • Phone: 706-513-2424
  • Fax: 706-396-3910
Mailing address:
  • Phone: 706-396-3900
  • Fax: 706-396-3910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: KYLE W PULLIAM
Title or Position: PHARMACY OWNER
Credential: RPH
Phone: 706-396-3900