Healthcare Provider Details

I. General information

NPI: 1619945912
Provider Name (Legal Business Name): A CARTER CLEMENTS JR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2006
Last Update Date: 03/11/2024
Certification Date: 03/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 1ST ST
RHINE GA
31077-3044
US

IV. Provider business mailing address

PO BOX 100
RHINE GA
31077-0100
US

V. Phone/Fax

Practice location:
  • Phone: 229-385-5351
  • Fax: 229-385-6807
Mailing address:
  • Phone: 229-385-5351
  • Fax: 229-385-6807

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number004653
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number004653
License Number StateGA

VIII. Authorized Official

Name: MR. ANDY CARTER CLEMENTS JR.
Title or Position: OWNER/PHARMACIST
Credential: PHARM D
Phone: 229-385-5351