=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841561453
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RX CORNER ENTERPRISES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/13/2012
-----------------------------------------------------
Last Update Date | 01/17/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 98 E OAKLAND AVE
-----------------------------------------------------
City | CAMILLA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31730-1529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-336-2255
-----------------------------------------------------
Fax | 229-336-2257
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 98 E OAKLAND AVE
-----------------------------------------------------
City | CAMILLA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31730-1529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-336-2255
-----------------------------------------------------
Fax | 229-336-2257
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST/OWNER
-----------------------------------------------------
Name | THOMAS MOYE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 229-225-7935
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PHRE009800
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------