Provider Demographics
NPI:1083678817
Name:SMITH, SPENCER REID (RPH)
Entity Type:Individual
Prefix:
First Name:SPENCER
Middle Name:REID
Last Name:SMITH
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 N VALHALLA CT
Mailing Address - Street 2:
Mailing Address - City:CORDELE
Mailing Address - State:GA
Mailing Address - Zip Code:31015-9308
Mailing Address - Country:US
Mailing Address - Phone:229-273-7513
Mailing Address - Fax:
Practice Address - Street 1:611 E LAMAR ST STE B
Practice Address - Street 2:
Practice Address - City:AMERICUS
Practice Address - State:GA
Practice Address - Zip Code:31709-3744
Practice Address - Country:US
Practice Address - Phone:229-928-9010
Practice Address - Fax:229-928-4477
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA017305183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA327980256AMedicaid