MEDICARE: CELESTINA PAK

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	1835P0018X	Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist	RPH028920	GA

General Provider Information

NPI Number	:	1508497256
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CELESTINA PAK

Provider Business Mailing Address
First Line	:	5664 JONESBORO RD
Second Line	:
City	:	LAKE CITY
State	:	GA
Zip	:	30260-3808
Country	:	US
Telephone Number	:	770-960-0162
Fax Number	:	770-960-2889

Provider Business Practice Location Address
First Line	:	5664 JONESBORO RD
Second Line	:
City	:	LAKE CITY
State	:	GA
Zip	:	30260-3808
Country	:	US
Telephone Number	:	770-960-0162
Fax Number	:	770-960-2889

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/31/2020
Last Update Date	:	01/31/2020

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Directions to “ CELESTINA PAK ” Practice Location

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