Provider Demographics
NPI:1346806221
Name:SMITH, LAWANDA BROOKE
Entity Type:Individual
Prefix:MRS
First Name:LAWANDA
Middle Name:BROOKE
Last Name:SMITH
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 1:408 EMPIRE SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:JESUP
Mailing Address - State:GA
Mailing Address - Zip Code:31545-2921
Mailing Address - Country:US
Mailing Address - Phone:912-221-0535
Mailing Address - Fax:
Practice Address - Street 1:955 S 1ST ST
Practice Address - Street 2:
Practice Address - City:JESUP
Practice Address - State:GA
Practice Address - Zip Code:31545-0331
Practice Address - Country:US
Practice Address - Phone:912-427-6239
Practice Address - Fax:912-427-6295
Is Sole Proprietor?:No
Enumeration Date:2019-05-15
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA029489183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist