Healthcare Provider Details

I. General information

NPI: 1033400072
Provider Name (Legal Business Name): WILLIAM JOSEPH PENDERGRAST PHARM.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2011
Last Update Date: 04/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1156 BIG A RD
TOCCOA GA
30577-6011
US

IV. Provider business mailing address

1156 BIG A RD
TOCCOA GA
30577-6011
US

V. Phone/Fax

Practice location:
  • Phone: 706-244-1630
  • Fax:
Mailing address:
  • Phone: 706-244-1630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH025443
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: