=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295283620
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CONVENIENT RX LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2016
-----------------------------------------------------
Last Update Date | 03/30/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 640 VETERANS PKWY N
-----------------------------------------------------
City | MOULTRIE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31788
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-890-6054
-----------------------------------------------------
Fax | 229-891-4087
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 861
-----------------------------------------------------
City | MOULTRIE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31776-0861
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-668-3005
-----------------------------------------------------
Fax | 229-668-3006
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. GREG YARBROUGH
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 229-668-3005
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PHRE010309
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------