Healthcare Provider Details

I. General information

NPI: 1366551624
Provider Name (Legal Business Name): CENTRAL GEORGIA CANCER CARE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 10/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 1ST ST STE 415
MACON GA
31201-8300
US

IV. Provider business mailing address

800 1ST ST STE 415
MACON GA
31201-8300
US

V. Phone/Fax

Practice location:
  • Phone: 478-314-1667
  • Fax: 478-743-7068
Mailing address:
  • Phone: 478-314-1667
  • Fax: 478-743-7068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHRE009011
License Number StateGA

VIII. Authorized Official

Name: AARON DAVIS
Title or Position: PIC
Credential: PHARMD
Phone: 478-743-7068