Provider Demographics
NPI:1508827171
Name:WILLIAMS, RICKY D (RPH)
Entity Type:Individual
Prefix:MR
First Name:RICKY
Middle Name:D
Last Name:WILLIAMS
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 1:500 W GORDON ST
Mailing Address - Street 2:
Mailing Address - City:THOMASTON
Mailing Address - State:GA
Mailing Address - Zip Code:30286-3415
Mailing Address - Country:US
Mailing Address - Phone:706-647-8965
Mailing Address - Fax:
Practice Address - Street 1:500 W GORDON ST
Practice Address - Street 2:
Practice Address - City:THOMASTON
Practice Address - State:GA
Practice Address - Zip Code:30286-3415
Practice Address - Country:US
Practice Address - Phone:706-647-8965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH011359183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00037067AMedicaid