Provider Demographics
NPI:1609823061
Name:PRUITTHEALTH PHARMACY SERVICES - VALDOSTA, INC.
Entity Type:Organization
Organization Name:PRUITTHEALTH PHARMACY SERVICES - VALDOSTA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN AND CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:NEIL
Authorized Official - Middle Name:L
Authorized Official - Last Name:PRUITT
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:770-279-6200
Mailing Address - Street 1:1626 JEURGENS CT
Mailing Address - Street 2:
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30093-2219
Mailing Address - Country:US
Mailing Address - Phone:678-533-6382
Mailing Address - Fax:770-931-5278
Practice Address - Street 1:1711 RIVER ST
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31601-5163
Practice Address - Country:US
Practice Address - Phone:229-244-8868
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-30
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00344044AMedicaid
GA4951130001Medicare NSC