Provider Demographics
NPI:1083796072
Name:HUBBARD, BRENDA GALE (RPH)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:GALE
Last Name:HUBBARD
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1820 S CARISBROOK PL
Mailing Address - Street 2:
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30168-5139
Mailing Address - Country:US
Mailing Address - Phone:770-819-7663
Mailing Address - Fax:
Practice Address - Street 1:1701 HARDEE AVE
Practice Address - Street 2:
Practice Address - City:FT MCPHERSON
Practice Address - State:GA
Practice Address - Zip Code:30330
Practice Address - Country:US
Practice Address - Phone:404-464-0306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA014579183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist