Healthcare Provider Details

I. General information

NPI: 1295176337
Provider Name (Legal Business Name): LANCE COPELAND FAGLIE PHARM.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2013
Last Update Date: 07/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

467 POOLER PKWY
POOLER GA
31322-5102
US

IV. Provider business mailing address

467 POOLER PKWY
POOLER GA
31322-5102
US

V. Phone/Fax

Practice location:
  • Phone: 912-330-7308
  • Fax:
Mailing address:
  • Phone: 912-330-7308
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH027262
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: