Provider Demographics
NPI:1407857303
Name:BROCK, MARCIA WILLIS (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MARCIA
Middle Name:WILLIS
Last Name:BROCK
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3077 FOWLSTOWN RD
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:39819-6632
Mailing Address - Country:US
Mailing Address - Phone:229-243-6163
Mailing Address - Fax:229-243-3327
Practice Address - Street 1:1500 E SHOTWELL ST
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:39819-4256
Practice Address - Country:US
Practice Address - Phone:229-243-6163
Practice Address - Fax:229-243-3327
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA018452183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist