Provider Demographics
NPI:1114054939
Name:LATCH, WILLIE OWEN (RPH)
Entity Type:Individual
Prefix:MR
First Name:WILLIE
Middle Name:OWEN
Last Name:LATCH
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 1:1203 RIVER RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-2215
Mailing Address - Country:US
Mailing Address - Phone:706-733-6502
Mailing Address - Fax:706-854-7643
Practice Address - Street 1:4315 BELAIR FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-9412
Practice Address - Country:US
Practice Address - Phone:706-854-7640
Practice Address - Fax:760-854-7643
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARHP012024183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist