=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780639518
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOVANS PHARMACY CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2006
-----------------------------------------------------
Last Update Date | 06/06/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6001 HIGHWAY 42
-----------------------------------------------------
City | REX
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30273-1030
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-968-5800
-----------------------------------------------------
Fax | 770-968-5855
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6001 HIGHWAY 42
-----------------------------------------------------
City | REX
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30273-1030
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MICHELLE LINDO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 678-481-3651
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PHRE009028
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------