Organization
SPECIALTY PHARMACY & COMPOUNDING
Active
Organization subpart
No
Provider details
NPI number
Authorized official
KEVIN CALLOSOE (SECRETARY)
(770) 596-6998
Entity
Organization
Contact information
Practice address
650 HENDERSON DR, SUITE 508, CARTERSVILLE, GA 30120-3744
(770) 607-3455
(770) 607-3457
Mailing address
650 HENDERSON DR, SUITE 508, CARTERSVILLE, GA 30120-3744
(770) 607-3455
(770) 607-3457
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
PHRE009616
GA
3336C0003X
Community/Retail Pharmacy
PHRE009616
GA
3336S0011X
Specialty Pharmacy
Primary
PHRE009616
GA
Other
Enumeration date
11/09/2009
Last updated
11/09/2009
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