Healthcare Provider Details

I. General information

NPI: 1083132484
Provider Name (Legal Business Name): VALDOSTA STATE UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2017
Last Update Date: 09/19/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 GEORGIA AVE
VALDOSTA GA
31698-3843
US

IV. Provider business mailing address

200 GEORGIA AVE
VALDOSTA GA
31602-3843
US

V. Phone/Fax

Practice location:
  • Phone: 229-219-3205
  • Fax: 229-249-2791
Mailing address:
  • Phone: 229-219-3205
  • Fax: 229-249-2791

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPHRE010386
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: LYNETTE LEWIS
Title or Position: ADMINISTRATOR
Credential:
Phone: 229-333-5886