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General NPI Number Information
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NPI Number | 1164596680
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Entity Type | Organization
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Legal Business Name | COLBERT PHARMACY INC 127 4TH ST
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Dates
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Enumeration Date | 11/17/2006
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Last Update Date | 06/07/2011
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Provider Practice Location Address
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Address Line | 5674 HIGHWAY 72 W
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City | COLBERT
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State | GA
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Zip | 30628-2934
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Country | US
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Telephone | 706-788-2102
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Fax | 706-788-9740
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Provider Business Mailing Address
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Address Line | PO BOX 336
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City | COLBERT
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State | GA
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Zip | 30628-0336
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Country | US
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Telephone | 706-788-2102
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Fax | 706-788-9470
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Authorized Official
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Title or Position | PRES
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Name | WALTER WHITE
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Credential | RPH
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Telephone | 706-788-2102
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | PHRE004838
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License Number State | GA
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