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General NPI Number Information
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NPI Number | 1013575604
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Entity Type | Organization
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Legal Business Name | TALLAPOOSA RX LLC
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Dates
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Enumeration Date | 05/30/2019
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Last Update Date | 12/21/2020
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Provider Practice Location Address
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Address Line | 2066 US HIGHWAY 78
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City | TALLAPOOSA
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State | GA
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Zip | 30176-1368
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Country | US
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Telephone | 770-574-2339
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 67
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City | TALLAPOOSA
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State | GA
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Zip | 30176-0067
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JACOB MOUCHET
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Credential | PHARM D
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Telephone | 770-574-2339
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number |
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License Number State |
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