MEDICARE: AQUILA INGRAM

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	183500000X	Pharmacist	PH14338	SC

General Provider Information

NPI Number	:	1730513730
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AQUILA INGRAM

Provider Business Mailing Address
First Line	:	6205 ALTA TOWNE LAKE CIR
Second Line	:
City	:	POOLER
State	:	GA
Zip	:	31322-5070
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7300 GA HIGHWAY 21
Second Line	:
City	:	SAVANNAH
State	:	GA
Zip	:	31407-9205
Country	:	US
Telephone Number	:	912-964-1791
Fax Number	:

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

Provider Enumeration Date	:	08/26/2013
Last Update Date	:	08/26/2013

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Directions to “ AQUILA INGRAM ” Practice Location

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