Provider Demographics
NPI:1235431495
Name:DURHAM, CHARLES WESLEY (PHARMD, BCPS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:WESLEY
Last Name:DURHAM
Suffix:
Gender:M
Credentials:PHARMD, BCPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3495 PIEDMONT RD NE BLDG 9
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-1729
Mailing Address - Country:US
Mailing Address - Phone:703-439-4986
Mailing Address - Fax:
Practice Address - Street 1:3495 PIEDMONT RD NE BLDG 9
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30305-1729
Practice Address - Country:US
Practice Address - Phone:703-439-4986
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-21
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHI-015156183700000X
390200000X
GALDO002227156FX1800X
VA02022129681835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183700000XPharmacy Service ProvidersPharmacy Technician
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
GALDO002227OtherSTATE LICENSE
VA0202212968OtherSTATE LICENSE
GAPHI-015156OtherSTATE LICENSE