Provider Demographics
NPI:1417249301
Name:HIGGINBOTHAM, OMER JR
Entity Type:Individual
Prefix:
First Name:OMER
Middle Name:
Last Name:HIGGINBOTHAM
Suffix:JR
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 1:200 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:FOLKSTON
Mailing Address - State:GA
Mailing Address - Zip Code:31537-3008
Mailing Address - Country:US
Mailing Address - Phone:912-496-7759
Mailing Address - Fax:912-496-1143
Practice Address - Street 1:200 N 2ND ST
Practice Address - Street 2:
Practice Address - City:FOLKSTON
Practice Address - State:GA
Practice Address - Zip Code:31537-3008
Practice Address - Country:US
Practice Address - Phone:912-496-7759
Practice Address - Fax:912-496-1143
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-10
Last Update Date:2011-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH013509183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist