MEDICARE: LAWRENCE JOEL ARMY HEALTH CLINIC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM1102X	Military Outpatient Operational (Transportable) Component Clinic/Center	11620	GA

General Provider Information

NPI Number	:	1265516470
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAWRENCE JOEL ARMY HEALTH CLINIC

Provider Business Mailing Address
First Line	:	2156 SPINK ST NW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30318-1154
Country	:	US
Telephone Number	:	404-792-5919
Fax Number	:

Provider Business Practice Location Address
First Line	:	1701 HARDEE AVE
Second Line	:
City	:	FT MCPHERSON
State	:	GA
Zip	:	30330
Country	:	US
Telephone Number	:	404-464-0304
Fax Number	:	404-464-0303

Authorized Official
Title or Position	:	STAFF PHARMACIST
Name	:	MRS. CARMEN RAKESTRAW AGNEW
Credential	:	RPH
Telephone Number	:	404-464-0304

Provider Enumeration Date	:	10/24/2006
Last Update Date	:	08/22/2020

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