Provider Demographics
NPI:1326338864
Name:TREBOTTE, LAUREL A
Entity Type:Individual
Prefix:
First Name:LAUREL
Middle Name:A
Last Name:TREBOTTE
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 1:1232 HIGHWAY 74 S
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-3072
Mailing Address - Country:US
Mailing Address - Phone:770-631-3766
Mailing Address - Fax:770-631-7765
Practice Address - Street 1:1232 HIGHWAY 74 S
Practice Address - Street 2:
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-3072
Practice Address - Country:US
Practice Address - Phone:770-631-3766
Practice Address - Fax:770-631-7765
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-18
Last Update Date:2011-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH023976183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist