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General NPI Number Information
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NPI Number | 1629132113
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Entity Type | Organization
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Legal Business Name | BLAKELY PHARMACY LLC
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Dates
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Enumeration Date | 12/20/2006
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Last Update Date | 12/07/2016
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Provider Practice Location Address
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Address Line | 90 COURT SQ
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City | BLAKELY
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State | GA
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Zip | 39823-2340
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Country | US
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Telephone | 229-723-3441
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Fax | 229-723-8707
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Provider Business Mailing Address
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Address Line | PO BOX 909
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City | BLAKELY
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State | GA
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Zip | 39823-0909
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PIC
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Name | LEIGH BRUNER
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Credential |
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Telephone | 229-723-3441
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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 | PHRE010001
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License Number State | GA
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