Healthcare Provider Details

I. General information

NPI: 1902853112
Provider Name (Legal Business Name): PRUITTHEALTH PHARMACY SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 03/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

377 NORTH POND STREET
TOCCOA GA
30577-1920
US

IV. Provider business mailing address

1626 JEURGENS CT
NORCROSS GA
30093-2219
US

V. Phone/Fax

Practice location:
  • Phone: 706-886-7787
  • Fax: 706-886-2939
Mailing address:
  • Phone: 770-279-6200
  • Fax: 770-279-6200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier00033767A
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer
# 2
Identifier0116756
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name: MR. NEIL L PRUITT JR.
Title or Position: CHAIRMAN AND CEO
Credential:
Phone: 770-279-6200