Provider Demographics
NPI:1144824210
Name:HATFIELD, GEORGE RUSSELL JR (RPH)
Entity type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:RUSSELL
Last Name:HATFIELD
Suffix:JR
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 1:346 E LANCASTER AVE APT 508
Mailing Address - Street 2:
Mailing Address - City:WYNNEWOOD
Mailing Address - State:PA
Mailing Address - Zip Code:19096-2233
Mailing Address - Country:US
Mailing Address - Phone:610-283-0150
Mailing Address - Fax:
Practice Address - Street 1:317 W LANCASTER AVE
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:PA
Practice Address - Zip Code:19003-1403
Practice Address - Country:US
Practice Address - Phone:610-658-0737
Practice Address - Fax:610-658-0943
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP040506L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PARP040506LMedicaid