Healthcare Provider Details

I. General information

NPI: 1447280672
Provider Name (Legal Business Name): PINE MOUNTAIN PHARMACY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 N MAIN AVE
PINE MOUNTAIN GA
31822-0500
US

IV. Provider business mailing address

PO BOX A 145 N MAIN AVE
PINE MOUNTAIN GA
31822-0500
US

V. Phone/Fax

Practice location:
  • Phone: 706-663-2255
  • Fax:
Mailing address:
  • Phone: 706-663-2255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number158
License Number StateGA

VIII. Authorized Official

Name: MR. CHARLES IVERSON STOREY III
Title or Position: PRESIDENT OWNER
Credential: RPH
Phone: 706-663-2255