Provider Demographics
NPI:1164057899
Name:HOLBROOK, CHASE
Entity Type:Individual
Prefix:
First Name:CHASE
Middle Name:
Last Name:HOLBROOK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:499 HENRY RD
Mailing Address - Street 2:
Mailing Address - City:SYLVESTER
Mailing Address - State:GA
Mailing Address - Zip Code:31791-7961
Mailing Address - Country:US
Mailing Address - Phone:229-349-1992
Mailing Address - Fax:
Practice Address - Street 1:262 CORDELE RD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31705-2407
Practice Address - Country:US
Practice Address - Phone:229-352-9459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-03
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA027240183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty