=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851882013
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LEE ARRENDALE STATE PRISON PHARMACY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2018
-----------------------------------------------------
Last Update Date | 05/23/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2023A GAINESVILLE HWY
-----------------------------------------------------
City | ALTO
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30510-4435
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-776-0661
-----------------------------------------------------
Fax | 706-776-4982
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 709
-----------------------------------------------------
City | ALTO
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30510-0709
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-776-0661
-----------------------------------------------------
Fax | 706-776-4982
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACY DIRECTOR
-----------------------------------------------------
Name | TOM POOLE
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 706-776-0661
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336I0012X
-----------------------------------------------------
Taxonomy Name | Institutional Pharmacy
-----------------------------------------------------
License Number | PHPR006157
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------