Healthcare Provider Details

I. General information

NPI: 1831181767
Provider Name (Legal Business Name): GLORIA E MACHALK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2005
Last Update Date: 12/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 E BROAD ST
LOUISVILLE GA
30434-1620
US

IV. Provider business mailing address

122 E BROAD ST
LOUISVILLE GA
30434-1620
US

V. Phone/Fax

Practice location:
  • Phone: 478-625-7575
  • Fax: 478-625-7575
Mailing address:
  • Phone: 478-625-7575
  • Fax: 478-625-7575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberPHRE006836
License Number StateGA

VIII. Authorized Official

Name: GLORIA ELAINE MACHALK
Title or Position: PHARMACIST
Credential:
Phone: 478-625-7575