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General NPI Number Information
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NPI Number | 1780755793
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Entity Type | Organization
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Legal Business Name | LA FAYETTE PRESCRIPTION SHOP
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Dates
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Enumeration Date | 11/13/2006
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Last Update Date | 07/19/2007
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Provider Practice Location Address
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Address Line | 700 E VILLANOW ST
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City | LA FAYETTE
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State | GA
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Zip | 30728-2619
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Country | US
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Telephone | 706-638-4347
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Fax | 706-638-7236
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Provider Business Mailing Address
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Address Line | 701 SUNSET MT DRIVE
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City | CHATTANOOPA
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State | TN
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Zip | 37421
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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 | PRESIDENT
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Name | RICHARD EZELL
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Credential |
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Telephone | 423-653-1750
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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 |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | PHRE006067
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License Number State | GA
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