Provider Demographics
NPI:1083105837
Name:HANNA, MARIO
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:
Last Name:HANNA
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 1:4575 ALTAMA AVE
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-3008
Mailing Address - Country:US
Mailing Address - Phone:912-261-2593
Mailing Address - Fax:912-261-8697
Practice Address - Street 1:4575 ALTAMA AVE
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-3008
Practice Address - Country:US
Practice Address - Phone:925-917-1507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-27
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA030461183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist