Basic Information
| Provider Information | |||||||||
| NPI: | 1275594095 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. CHARLES HEALTH COUNCIL, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | STONE MOUNTAIN HEALTH SERVICES PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 159 | ||||||||
| Address2: | |||||||||
| City: | EWING | ||||||||
| State: | VA | ||||||||
| PostalCode: | 242480159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2764454826 | ||||||||
| FaxNumber: | 2765463440 | ||||||||
| Practice Location | |||||||||
| Address1: | HIGHWAY 58 | ||||||||
| Address2: | |||||||||
| City: | EWING | ||||||||
| State: | VA | ||||||||
| PostalCode: | 242480159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2764454826 | ||||||||
| FaxNumber: | 2765463440 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2006 | ||||||||
| LastUpdateDate: | 09/04/2007 | ||||||||
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| AuthorizedOfficialLastName: | PERDUE | ||||||||
| AuthorizedOfficialFirstName: | MALCOLM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2765465310 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | Y | Suppliers | Pharmacy |
No ID Information.