Provider Demographics
NPI:1508304437
Name:BROOKS, CARSON
Entity Type:Individual
Prefix:
First Name:CARSON
Middle Name:
Last Name:BROOKS
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 1:579 MOCKINGBIRD RD
Mailing Address - Street 2:
Mailing Address - City:ABBEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31001-6137
Mailing Address - Country:US
Mailing Address - Phone:229-322-9683
Mailing Address - Fax:
Practice Address - Street 1:579 MOCKINGBIRD RD
Practice Address - Street 2:
Practice Address - City:ABBEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31001-6137
Practice Address - Country:US
Practice Address - Phone:229-322-9683
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-12
Last Update Date:2017-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA027437183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist