Provider Demographics
NPI:1295019495
Name:JOHN, PANACKAL O
Entity Type:Individual
Prefix:MR
First Name:PANACKAL
Middle Name:O
Last Name:JOHN
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 1:2304 MALDEN PARK DR
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30519
Mailing Address - Country:US
Mailing Address - Phone:678-985-2712
Mailing Address - Fax:
Practice Address - Street 1:472 S ENOTA DR
Practice Address - Street 2:
Practice Address - City:GAINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501
Practice Address - Country:US
Practice Address - Phone:770-535-3750
Practice Address - Fax:770-535-4071
Is Sole Proprietor?:No
Enumeration Date:2011-10-06
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH021035183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist