Healthcare Provider Details

I. General information

NPI: 1386949550
Provider Name (Legal Business Name): DJK 36 INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2011
Last Update Date: 05/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 S DOOLY ST
MONTEZUMA GA
31063-1604
US

IV. Provider business mailing address

PO BOX 250
MONTEZUMA GA
31063-0250
US

V. Phone/Fax

Practice location:
  • Phone: 478-472-7561
  • Fax: 478-472-5887
Mailing address:
  • Phone: 478-472-7561
  • Fax: 478-472-5887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHRE003393
License Number StateGA

VIII. Authorized Official

Name: DANIEL KISER
Title or Position: PHARMACIST IN CHARGE/OWNER
Credential:
Phone: 478-472-7561