Provider Demographics
NPI:1265683684
Name:COUCH, JERE DOUGLAS (RPH)
Entity Type:Individual
Prefix:
First Name:JERE
Middle Name:DOUGLAS
Last Name:COUCH
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 1:155 PORTICO PL
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-5947
Mailing Address - Country:US
Mailing Address - Phone:770-328-3302
Mailing Address - Fax:
Practice Address - Street 1:155 PORTICO PL
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-5947
Practice Address - Country:US
Practice Address - Phone:770-328-3302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-03
Last Update Date:2008-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH11382183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist