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General NPI Number Information
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NPI Number | 1629433529
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Entity Type | Organization
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Legal Business Name | YOUR CORNER DRUG STORE LLC
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Dates
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Enumeration Date | 12/18/2015
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Last Update Date | 04/19/2017
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Provider Practice Location Address
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Address Line | 4260 LOG CABIN DR STE C
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City | MACON
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State | GA
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Zip | 31204-4852
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Country | US
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Telephone | 478-254-8484
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Fax | 478-254-8020
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Provider Business Mailing Address
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Address Line | 104 LORRAINE FOREST CT
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City | MACON
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State | GA
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Zip | 31210-5316
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Country | US
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Telephone | 478-994-1189
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MATTHEW FRAZIER
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Credential | PHARMD
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Telephone | 478-254-8484
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0004X
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Taxonomy Name | Compounding 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 | 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 #3
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | PHRE010205
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License Number State | GA
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