Provider Demographics
NPI:1043811755
Name:DUBUC, WYNN BRUNELLE (PHARMD)
Entity Type:Individual
Prefix:
First Name:WYNN
Middle Name:BRUNELLE
Last Name:DUBUC
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4236 SINGING POST LN NE
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-2689
Mailing Address - Country:US
Mailing Address - Phone:770-552-9178
Mailing Address - Fax:
Practice Address - Street 1:4480 S COBB DR SE
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-6990
Practice Address - Country:US
Practice Address - Phone:770-434-8560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-09
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH032088183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist