Provider Demographics
NPI:1407450331
Name:BUTLER, THEOTUS
Entity Type:Individual
Prefix:
First Name:THEOTUS
Middle Name:
Last Name:BUTLER
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 1:1622 S LUMPKIN RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31903-2720
Mailing Address - Country:US
Mailing Address - Phone:678-725-5797
Mailing Address - Fax:706-682-5282
Practice Address - Street 1:1622 S LUMPKIN RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31903-2720
Practice Address - Country:US
Practice Address - Phone:706-682-5282
Practice Address - Fax:706-682-3547
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-22
Last Update Date:2020-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA018199183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist