Provider Demographics
NPI:1003030123
Name:JAMES, PHILLIP R
Entity Type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:R
Last Name:JAMES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 TANGLEWOOD S
Mailing Address - Street 2:
Mailing Address - City:ROYSTON
Mailing Address - State:GA
Mailing Address - Zip Code:30662-3770
Mailing Address - Country:US
Mailing Address - Phone:706-245-4169
Mailing Address - Fax:
Practice Address - Street 1:13387 JONES ST
Practice Address - Street 2:
Practice Address - City:LAVONIA
Practice Address - State:GA
Practice Address - Zip Code:30553-1164
Practice Address - Country:US
Practice Address - Phone:706-356-4153
Practice Address - Fax:706-356-2849
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA015594183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist