Provider Demographics
NPI:1164739918
Name:EVERETT, ROBERT ERVIN JR (RPH)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:ERVIN
Last Name:EVERETT
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:PO BOX 367
Mailing Address - Street 2:1050 CLOTFELTER LN
Mailing Address - City:BOGART
Mailing Address - State:GA
Mailing Address - Zip Code:30622-0367
Mailing Address - Country:US
Mailing Address - Phone:706-338-7657
Mailing Address - Fax:
Practice Address - Street 1:1918 RAILROAD ST
Practice Address - Street 2:
Practice Address - City:STATHAM
Practice Address - State:GA
Practice Address - Zip Code:30666-1875
Practice Address - Country:US
Practice Address - Phone:706-725-1122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-31
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH013637183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist