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General NPI Number Information
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NPI Number | 1861504706
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Entity Type | Organization
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Legal Business Name | MAXWELL HOUSE PHARMACY LLC
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Dates
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Enumeration Date | 08/31/2006
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Last Update Date | 03/23/2011
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Provider Practice Location Address
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Address Line | 1002 GREENE ST
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City | AUGUSTA
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State | GA
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Zip | 30901-2251
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Country | US
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Telephone | 706-722-4695
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Fax | 706-722-4696
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Provider Business Mailing Address
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Address Line | 1002 GREENE ST
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City | AUGUSTA
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State | GA
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Zip | 30901-2251
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Country | US
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Telephone | 706-722-4695
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Fax | 706-722-4696
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Authorized Official
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Title or Position | OWNER
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Name | KEITH MATTHEWS
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Credential |
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Telephone | 803-637-5757
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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 | PHRE002600
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License Number State | GA
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