Provider Demographics
NPI:1174821755
Name:THOMAS, JUSTIN
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:THOMAS
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 1:2 W MAIN ST.
Mailing Address - Street 2:
Mailing Address - City:CLAXTON
Mailing Address - State:GA
Mailing Address - Zip Code:30417-1752
Mailing Address - Country:US
Mailing Address - Phone:912-739-0406
Mailing Address - Fax:912-739-2824
Practice Address - Street 1:2 W MAIN ST.
Practice Address - Street 2:
Practice Address - City:CLAXTON
Practice Address - State:GA
Practice Address - Zip Code:30417-1752
Practice Address - Country:US
Practice Address - Phone:912-739-0406
Practice Address - Fax:912-739-2824
Is Sole Proprietor?:No
Enumeration Date:2011-03-07
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH025046183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist