Healthcare Provider Details

I. General information

NPI: 1639115025
Provider Name (Legal Business Name): CLINIC PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 07/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

58 BIG A RD SUITE 101
TOCCOA GA
30577-6017
US

IV. Provider business mailing address

58 BIG A RD SUITE 101
TOCCOA GA
30577
US

V. Phone/Fax

Practice location:
  • Phone: 706-886-2151
  • Fax: 706-297-7519
Mailing address:
  • Phone: 706-886-2151
  • Fax: 706-297-7519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHRE002911
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier2019114
Identifier TypeOTHER
Identifier State
Identifier IssuerPK
# 2
Identifier00647017A
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer

VIII. Authorized Official

Name: KIMBERLY BEECHER ELROD
Title or Position: OWNER/PHARMACIST-IN-CHARGE
Credential:
Phone: 706-886-2151