Provider Demographics
NPI:1053452045
Name:BASS, RICHARD TRUITT (RPH)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:TRUITT
Last Name:BASS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:107 LAKEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31788-8706
Mailing Address - Country:US
Mailing Address - Phone:229-985-6389
Mailing Address - Fax:229-985-5600
Practice Address - Street 1:101 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-3863
Practice Address - Country:US
Practice Address - Phone:229-985-9080
Practice Address - Fax:229-985-5600
Is Sole Proprietor?:No
Enumeration Date:2007-02-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA12522183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist