=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912976630
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOODYCARE INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 380 HOSPITAL DR. STE 175-A
-----------------------------------------------------
City | MACON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-745-5431
-----------------------------------------------------
Fax | 478-765-4359
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 380 HOSPITAL DR. STE 175-A
-----------------------------------------------------
City | MACON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-745-5431
-----------------------------------------------------
Fax | 478-765-4359
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. ROBERT BENJAMIN MOODY III
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 478-745-5431
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | PHRE004996
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------