Basic Information
Provider Information | |||||||||
NPI: | 1821690173 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PURCELL | ||||||||
FirstName: | MAGGIE | ||||||||
MiddleName: | BROOKE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHARMD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1467 IG LANIER RD | ||||||||
Address2: |   | ||||||||
City: | PEMBROKE | ||||||||
State: | GA | ||||||||
PostalCode: | 313215667 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9126637381 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 349 BRAMPTON AVE | ||||||||
Address2: |   | ||||||||
City: | STATESBORO | ||||||||
State: | GA | ||||||||
PostalCode: | 304580832 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9124894643 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/11/2020 | ||||||||
LastUpdateDate: | 11/11/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/11/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | RPH030099 | GA | Y |   | Pharmacy Service Providers | Pharmacist |   |
No ID Information.