Provider Demographics
NPI:1417971789
Name:EWING, GESTON GARNER (RPH)
Entity Type:Individual
Prefix:
First Name:GESTON
Middle Name:GARNER
Last Name:EWING
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 S GRANT ST
Mailing Address - Street 2:
Mailing Address - City:FITZGERALD
Mailing Address - State:GA
Mailing Address - Zip Code:31750-3312
Mailing Address - Country:US
Mailing Address - Phone:229-423-9801
Mailing Address - Fax:229-423-9496
Practice Address - Street 1:502 S GRANT ST
Practice Address - Street 2:
Practice Address - City:FITZGERALD
Practice Address - State:GA
Practice Address - Zip Code:31750-3312
Practice Address - Country:US
Practice Address - Phone:229-423-9801
Practice Address - Fax:229-423-9496
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004374183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0025231AMedicaid
GA5529980001Medicare ID - Type Unspecified