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General NPI Number Information
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NPI Number | 1184115321
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Entity Type | Organization
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Legal Business Name | GEORGIA STATE PRISON REGIONAL PHARMACY
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Dates
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Enumeration Date | 05/23/2018
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Last Update Date | 05/23/2018
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Provider Practice Location Address
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Address Line | 300 1ST AVE S
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City | REIDSVILLE
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State | GA
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Zip | 30453-9304
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Country | US
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Telephone | 912-557-7960
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Fax | 912-557-7975
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Provider Business Mailing Address
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Address Line | 300 1ST AVE S
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City | REIDSVILLE
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State | GA
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Zip | 30453-9304
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Country | US
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Telephone | 912-557-7960
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Fax | 912-557-7975
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Authorized Official
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Title or Position | PHARMACY DIRECTOR
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Name | MR. BENJAMIN CLARK
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Credential |
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Telephone | 912-557-7960
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336I0012X
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Taxonomy Name | Institutional Pharmacy
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License Number | PHH005792
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License Number State | GA
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