=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770516973
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CORLEY & MCCLENDON INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/09/2006
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 523 SOUTH GREENWOOD STREET
-----------------------------------------------------
City | LAGRANGE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30240
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-884-2661
-----------------------------------------------------
Fax | 706-884-5446
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18 NEW AIRPORT ROAD
-----------------------------------------------------
City | LAGRANGE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30240
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-885-9213
-----------------------------------------------------
Fax | 706-885-9829
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | RPH
-----------------------------------------------------
Name | MR. JAMES DAVID COCHRAN
-----------------------------------------------------
Credential | OWNER/PHARMACIEST
-----------------------------------------------------
Telephone | 706-884-2661
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PHRE004797
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------