Healthcare Provider Details

I. General information

NPI: 1174627426
Provider Name (Legal Business Name): COLLEGE PHARMACY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2006
Last Update Date: 10/02/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 S MAIN ST
STATESBORO GA
30458-5245
US

IV. Provider business mailing address

35 S MAIN ST
STATESBORO GA
30458-5245
US

V. Phone/Fax

Practice location:
  • Phone: 912-489-4663
  • Fax: 912-489-3129
Mailing address:
  • Phone: 912-489-4663
  • Fax: 912-489-3129

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336H0001X
TaxonomyHome Infusion Therapy Pharmacy
License NumberPHRE007767
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number State

VIII. Authorized Official

Name: MR. MICHAEL JAMES GUERNSEY
Title or Position: MANAGER
Credential:
Phone: 912-489-4663