Provider Demographics
NPI:1215560123
Name:MCCULLEY, JENNIFER ANNE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANNE
Last Name:MCCULLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4321 HARTLEY BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31216-5641
Mailing Address - Country:US
Mailing Address - Phone:478-788-1015
Mailing Address - Fax:478-788-2050
Practice Address - Street 1:4321 HARTLEY BRIDGE RD
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31216-5641
Practice Address - Country:US
Practice Address - Phone:478-788-1015
Practice Address - Fax:478-788-2050
Is Sole Proprietor?:No
Enumeration Date:2020-02-19
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA173261835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist