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General NPI Number Information
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NPI Number | 1902397995
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Entity Type | Organization
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Legal Business Name | PULASKI STATE PRISON REGIONAL PHARMACY
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Dates
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Enumeration Date | 05/24/2018
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Last Update Date | 05/24/2018
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Provider Practice Location Address
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Address Line | 373 UPPER RIVER RD
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City | HAWKINSVILLE
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State | GA
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Zip | 31036-8898
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Country | US
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Telephone | 478-783-6097
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Fax | 478-783-6252
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Provider Business Mailing Address
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Address Line | 373 UPPER RIVER RD
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City | HAWKINSVILLE
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State | GA
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Zip | 31036-8898
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Country | US
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Telephone | 478-783-6097
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Fax | 478-783-6252
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Authorized Official
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Title or Position | PHARMACY DIRECTOR
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Name | RANDY GOODROE
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Credential | RPH
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Telephone | 478-783-6097
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336I0012X
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Taxonomy Name | Institutional Pharmacy
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License Number | PHPR007792
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License Number State | GA
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