Provider Demographics
NPI:1083202477
Name:LEWIS, AUTUMN (PHAMRD)
Entity Type:Individual
Prefix:
First Name:AUTUMN
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:PHAMRD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9925 BARNSBURY RD
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-3176
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9925 BARNSBURY RD
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-3176
Practice Address - Country:US
Practice Address - Phone:679-778-5963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-01
Last Update Date:2021-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA021290183500000X
333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No183500000XPharmacy Service ProvidersPharmacist