Provider Demographics
NPI:1366637142
Name:BOZEMAN, RUSSELL JAY
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:JAY
Last Name:BOZEMAN
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 1:10929 US HIGHWAY 301 S
Mailing Address - Street 2:SUITE 111
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-7774
Mailing Address - Country:US
Mailing Address - Phone:912-764-7839
Mailing Address - Fax:912-489-1519
Practice Address - Street 1:10929 US HIGHWAY 301 S
Practice Address - Street 2:SUITE 111
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-7774
Practice Address - Country:US
Practice Address - Phone:912-764-7839
Practice Address - Fax:912-489-1519
Is Sole Proprietor?:No
Enumeration Date:2007-09-13
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA147821835G0303X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835G0303XPharmacy Service ProvidersPharmacistGeriatric