Healthcare Provider Details

I. General information

NPI: 1013575604
Provider Name (Legal Business Name): TALLAPOOSA RX LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2019
Last Update Date: 12/21/2020
Certification Date: 12/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2066 US HIGHWAY 78
TALLAPOOSA GA
30176-1368
US

IV. Provider business mailing address

PO BOX 67
TALLAPOOSA GA
30176-0067
US

V. Phone/Fax

Practice location:
  • Phone: 770-574-2339
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JACOB MOUCHET
Title or Position: OWNER
Credential: PHARM D
Phone: 770-574-2339