Basic Information
| Provider Information | |||||||||
| NPI: | 1154897189 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRUITTHEALTH PHARMACY SERVICES - DURHAM, INC. | ||||||||
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| OtherOrganizationName: | PRUITTHEALTH PHARMACY SERVICES - DURHAM | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1626 JEURGENS CT | ||||||||
| Address2: | |||||||||
| City: | NORCROSS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300932219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6785336382 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4024 STIRRUP CREEK DRIVE | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277038971 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003902906 | ||||||||
| FaxNumber: | 9194849009 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2018 | ||||||||
| LastUpdateDate: | 06/03/2021 | ||||||||
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| AuthorizedOfficialLastName: | PRUITT | ||||||||
| AuthorizedOfficialFirstName: | NEIL | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHAIRMAN AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 7702796200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | N | Laboratories | Clinical Medical Laboratory | 3336C0003X | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
No ID Information.