Provider Demographics
NPI:1326455502
Name:CAMPBELL, MISTY SHAY
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:SHAY
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MISTY
Other - Middle Name:SHAY
Other - Last Name:RIEDMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1601 HWY 40 E
Mailing Address - Street 2:
Mailing Address - City:KINGSLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31548-6500
Mailing Address - Country:US
Mailing Address - Phone:912-729-6170
Mailing Address - Fax:912-729-7700
Practice Address - Street 1:1601 HWY 40 E
Practice Address - Street 2:
Practice Address - City:KINGSLAND
Practice Address - State:GA
Practice Address - Zip Code:31548-6500
Practice Address - Country:US
Practice Address - Phone:912-729-6170
Practice Address - Fax:912-729-7700
Is Sole Proprietor?:No
Enumeration Date:2014-07-19
Last Update Date:2014-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH019164183500000X
FLPS 50880183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist