Basic Information
| Provider Information | |||||||||
| NPI: | 1952638579 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRUITTHEALTH PHARMACY SERVICES - CHRISTIAN CITY, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PRUITTHEALTH PHARMACY SERVICES - CHRISTIAN CITY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1626 JEURGENS CT | ||||||||
| Address2: | |||||||||
| City: | NORCROSS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300932219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702796200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7300 LESTER RD | ||||||||
| Address2: | BLDG P | ||||||||
| City: | UNION CITY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302912328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702105900 | ||||||||
| FaxNumber: | 7705001116 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2009 | ||||||||
| LastUpdateDate: | 06/03/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PRUITT | ||||||||
| AuthorizedOfficialFirstName: | NEIL | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHAIRMAN & CEO OF MGR | ||||||||
| AuthorizedOfficialTelephone: | 7702796200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | N | Laboratories | Clinical Medical Laboratory | 3336C0003X | PHRE009656 | GA | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 3336I0012X | PHRE009656 | GA | N | Suppliers | Pharmacy | Institutional Pharmacy | 3336L0003X | PHRE009656 | GA | Y | Suppliers | Pharmacy | Long Term Care Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 1160023 | 01 | GA | NCPDP | OTHER | 474085527A | 05 | GA | MEDICAID |