MEDICARE: PINE MOUNTAIN PHARMACY, INC

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	3336C0003X	Community/Retail Pharmacy	158	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1112969	OTHER	GA	NABP

General Provider Information

NPI Number	:	1447280672
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PINE MOUNTAIN PHARMACY, INC

Provider Business Mailing Address
First Line	:	PO BOX A
Second Line	:	145 N MAIN AVE
City	:	PINE MOUNTAIN
State	:	GA
Zip	:	31822-0500
Country	:	US
Telephone Number	:	706-663-2255
Fax Number	:

Provider Business Practice Location Address
First Line	:	145 N MAIN AVE
Second Line	:
City	:	PINE MOUNTAIN
State	:	GA
Zip	:	31822-0500
Country	:	US
Telephone Number	:	706-663-2255
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT OWNER
Name	:	MR. CHARLES IVERSON STOREY III
Credential	:	RPH
Telephone Number	:	706-663-2255

Provider Enumeration Date	:	07/04/2006
Last Update Date	:	08/22/2020

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