MEDICARE: ROBERT CECIL ENTERPRISES 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	333600000X	Pharmacy
2	3336L0003X	Long Term Care Pharmacy
3	3336C0004X	Compounding Pharmacy
4	3336C0003X	Community/Retail Pharmacy	PHRE006319	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1113036	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1588680433
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROBERT CECIL ENTERPRISES INC

Provider Business Mailing Address
First Line	:	4045 LINDLEY CIR
Second Line	:	SUITE D
City	:	POWDER SPRINGS
State	:	GA
Zip	:	30127-2764
Country	:	US
Telephone Number	:	770-943-3566
Fax Number	:	770-943-0723

Provider Business Practice Location Address
First Line	:	4045 LINDLEY CIR
Second Line	:	SUITE D
City	:	POWDER SPRINGS
State	:	GA
Zip	:	30127-2764
Country	:	US
Telephone Number	:	770-943-3566
Fax Number	:	770-943-0723

Authorized Official
Title or Position	:	OWNER PHCST
Name	:	ROBERT CECIL
Credential	:	RPH
Telephone Number	:	770-943-3566

Provider Enumeration Date	:	07/14/2006
Last Update Date	:	11/23/2011

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