Healthcare Provider Details

I. General information

NPI: 1801931555
Provider Name (Legal Business Name): CHANCY DRUGS MOULTRIE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 01/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 N MAIN ST
MOULTRIE GA
31768-3863
US

IV. Provider business mailing address

205B E MAIN ST
HAHIRA GA
31632-1121
US

V. Phone/Fax

Practice location:
  • Phone: 229-985-9080
  • Fax: 229-985-5600
Mailing address:
  • Phone: 229-794-3525
  • Fax: 229-794-1059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPHRE010195
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: HUGH CHANCY
Title or Position: OWNER
Credential:
Phone: 229-794-3525