Provider Demographics
NPI:1508133141
Name:AULT, ROBERT CARL (RPH)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:CARL
Last Name:AULT
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 1:214 N VARNELL RD
Mailing Address - Street 2:
Mailing Address - City:TUNNEL HILL
Mailing Address - State:GA
Mailing Address - Zip Code:30755-9219
Mailing Address - Country:US
Mailing Address - Phone:706-673-2001
Mailing Address - Fax:
Practice Address - Street 1:1308 W WALNUT AVE
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-3827
Practice Address - Country:US
Practice Address - Phone:706-618-2130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-28
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA012519183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist