Provider Demographics
NPI:1073113676
Name:OBENAUER, JULIE
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:
Last Name:OBENAUER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:917 ABINGDON CV
Mailing Address - Street 2:
Mailing Address - City:BONAIRE
Mailing Address - State:GA
Mailing Address - Zip Code:31005-3880
Mailing Address - Country:US
Mailing Address - Phone:716-548-4446
Mailing Address - Fax:
Practice Address - Street 1:1215 E 16TH AVE
Practice Address - Street 2:
Practice Address - City:CORDELE
Practice Address - State:GA
Practice Address - Zip Code:31015-4585
Practice Address - Country:US
Practice Address - Phone:229-273-9270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-01
Last Update Date:2020-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH030183183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist