Healthcare Provider Details

I. General information

NPI: 1073430393
Provider Name (Legal Business Name): ANDREW KILPATRICK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2026
Last Update Date: 06/30/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 BLUE MOON XING
POOLER GA
31322-9797
US

IV. Provider business mailing address

101 BLUE MOON XING
POOLER GA
31322-9797
US

V. Phone/Fax

Practice location:
  • Phone: 912-450-1070
  • Fax:
Mailing address:
  • Phone: 912-450-1070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH036287
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: