=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063669315
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEDEQUIP HEALTH CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/19/2008
-----------------------------------------------------
Last Update Date | 08/19/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 465 N BELAIR RD 1A2
-----------------------------------------------------
City | EVANS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30809-3188
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-855-5502
-----------------------------------------------------
Fax | 706-854-2425
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 465 N BELAIR RD STE 1A2
-----------------------------------------------------
City | EVANS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30809-3188
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-855-5502
-----------------------------------------------------
Fax | 706-854-2425
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST
-----------------------------------------------------
Name | KYLE W PULLIAM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 706-855-5502
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0004X
-----------------------------------------------------
Taxonomy Name | Compounding Pharmacy
-----------------------------------------------------
License Number | PHRE009484
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------