Provider Demographics
NPI:1164711867
Name:VERNON, JAMES ROBERT (RPH)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:ROBERT
Last Name:VERNON
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 1:645 RUSSELL RD
Mailing Address - Street 2:RITE AID PHARMACY STORE # 11699
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-3637
Mailing Address - Country:US
Mailing Address - Phone:770-682-5512
Mailing Address - Fax:770-962-7629
Practice Address - Street 1:645 RUSSELL RD
Practice Address - Street 2:RITE AID PHARMACY STORE # 11699
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-3637
Practice Address - Country:US
Practice Address - Phone:770-682-5512
Practice Address - Fax:770-962-7629
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-04
Last Update Date:2011-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist