Healthcare Provider Details

I. General information

NPI: 1760410567
Provider Name (Legal Business Name): WALTER HENRY PRUITT II R.PH.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 01/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1197 BIG A RD
TOCCOA GA
30577-6028
US

IV. Provider business mailing address

5709 OAK VALLEY RD
TOCCOA GA
30577-7293
US

V. Phone/Fax

Practice location:
  • Phone: 706-886-8711
  • Fax: 706-886-4956
Mailing address:
  • Phone: 706-886-0530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number012920
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: