Provider Demographics
NPI:1356749592
Name:PRUITTHEALTH PHARMACY SERVICES - CHARLOTTE HALL, INC
Entity type:Organization
Organization Name:PRUITTHEALTH PHARMACY SERVICES - CHARLOTTE HALL, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROVIDER ENROLLMENT SPECIALIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:LYNETHIA
Authorized Official - Middle Name:N
Authorized Official - Last Name:HOLLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-506-6875
Mailing Address - Street 1:1626 JEURGENS CT
Mailing Address - Street 2:
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30093
Mailing Address - Country:US
Mailing Address - Phone:770-279-6200
Mailing Address - Fax:833-679-5232
Practice Address - Street 1:29449 CHARLOTTE HALL RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE HALL
Practice Address - State:MD
Practice Address - Zip Code:20622
Practice Address - Country:US
Practice Address - Phone:704-548-7730
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-19
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDPW0548OtherSTATE LICENSE
MD269091800Medicaid