Provider Demographics
NPI:1417230244
Name:MAR, TOM
Entity Type:Individual
Prefix:
First Name:TOM
Middle Name:
Last Name:MAR
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 1:139 ADAMS LAKE CT
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-5322
Mailing Address - Country:US
Mailing Address - Phone:770-237-9875
Mailing Address - Fax:
Practice Address - Street 1:3900 WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:GA
Practice Address - Zip Code:30907-2322
Practice Address - Country:US
Practice Address - Phone:706-868-8084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-28
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH018780183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist