Provider Demographics
NPI:1952638579
Name:PRUITTHEALTH PHARMACY SERVICES - CHRISTIAN CITY, LLC
Entity Type:Organization
Organization Name:PRUITTHEALTH PHARMACY SERVICES - CHRISTIAN CITY, LLC
Other - Org Name:PRUITTHEALTH PHARMACY SERVICES - CHRISTIAN CITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHAIRMAN & CEO OF MGR
Authorized Official - Prefix:
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:770-279-6200
Mailing Address - Fax:
Practice Address - Street 1:7300 LESTER RD
Practice Address - Street 2:BLDG P
Practice Address - City:UNION CITY
Practice Address - State:GA
Practice Address - Zip Code:30291-2328
Practice Address - Country:US
Practice Address - Phone:770-210-5900
Practice Address - Fax:770-500-1116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-04
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
291U00000X
GAPHRE0096563336C0003X, 3336I0012X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No291U00000XLaboratoriesClinical Medical Laboratory
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1160023OtherNCPDP
GA474085527AMedicaid
GA1160023OtherNCPDP