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General NPI Number Information
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NPI Number | 1386949550
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Entity Type | Organization
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Legal Business Name | DJK 36 INC
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Dates
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Enumeration Date | 01/20/2011
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Last Update Date | 05/09/2011
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Provider Practice Location Address
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Address Line | 112 S DOOLY ST
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City | MONTEZUMA
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State | GA
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Zip | 31063-1604
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Country | US
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Telephone | 478-472-7561
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Fax | 478-472-5887
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Provider Business Mailing Address
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Address Line | PO BOX 250
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City | MONTEZUMA
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State | GA
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Zip | 31063-0250
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Country | US
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Telephone | 478-472-7561
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Fax | 478-472-5887
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Authorized Official
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Title or Position | PHARMACIST IN CHARGE/OWNER
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Name | DANIEL KISER
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Credential |
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Telephone | 478-472-7561
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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 | PHRE003393
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License Number State | GA
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