Provider Demographics
NPI:1477965267
Name:WALBORN, LORETTA (PHARMD)
Entity Type:Individual
Prefix:
First Name:LORETTA
Middle Name:
Last Name:WALBORN
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 1:97 COMMERCE DRIVE
Mailing Address - Street 2:
Mailing Address - City:BLUERIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30513
Mailing Address - Country:US
Mailing Address - Phone:706-632-9508
Mailing Address - Fax:
Practice Address - Street 1:192 1ST AVE
Practice Address - Street 2:
Practice Address - City:EAST ELLIJAY
Practice Address - State:GA
Practice Address - Zip Code:30540-8101
Practice Address - Country:US
Practice Address - Phone:706-635-2241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-28
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH022564183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist