MEDICARE: JOVANS PHARMACY CORP

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	PHRE009028	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1154361	OTHER		OTHER ID NUMBER

General Provider Information

NPI Number	:	1780639518
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOVANS PHARMACY CORP

Provider Business Mailing Address
First Line	:	6001 HIGHWAY 42
Second Line	:
City	:	REX
State	:	GA
Zip	:	30273-1030
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6001 HIGHWAY 42
Second Line	:
City	:	REX
State	:	GA
Zip	:	30273-1030
Country	:	US
Telephone Number	:	770-968-5800
Fax Number	:	770-968-5855

Authorized Official
Title or Position	:	CEO
Name	:	MICHELLE LINDO
Credential	:
Telephone Number	:	678-481-3651

Provider Enumeration Date	:	05/23/2006
Last Update Date	:	06/06/2008

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Directions to “JOVANS PHARMACY CORP ” Practice Location

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