Provider Demographics
NPI:1790908622
Name:EAST GEORGIA PREVENTATIVE HEALTH SPECIALISTS, LLC
Entity Type:Organization
Organization Name:EAST GEORGIA PREVENTATIVE HEALTH SPECIALISTS, LLC
Other - Org Name:EAST GEORGIA COMPOUNDING AND WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BOBBY
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:STONE
Authorized Official - Suffix:JR
Authorized Official - Credentials:RPH, CDM
Authorized Official - Phone:912-685-7498
Mailing Address - Street 1:150 S LEROY ST STE A
Mailing Address - Street 2:
Mailing Address - City:METTER
Mailing Address - State:GA
Mailing Address - Zip Code:30439-4631
Mailing Address - Country:US
Mailing Address - Phone:912-685-7498
Mailing Address - Fax:912-685-3777
Practice Address - Street 1:150 S LEROY ST STE A
Practice Address - Street 2:
Practice Address - City:METTER
Practice Address - State:GA
Practice Address - Zip Code:30439-4631
Practice Address - Country:US
Practice Address - Phone:912-685-7498
Practice Address - Fax:912-685-3777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0088293336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy