=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871223628
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BROXTON FAMILY PHARMACY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2022
-----------------------------------------------------
Last Update Date | 01/04/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 402 ALABAMA ST N
-----------------------------------------------------
City | BROXTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31519-6001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-359-2362
-----------------------------------------------------
Fax | 912-359-2370
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 402 ALABAMA ST N
-----------------------------------------------------
City | BROXTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31519-6001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-359-2362
-----------------------------------------------------
Fax | 912-359-2370
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CFO
-----------------------------------------------------
Name | DR. JAMES ANDREW HOLT
-----------------------------------------------------
Credential | PHARM D
-----------------------------------------------------
Telephone | 912-359-2362
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------