Provider Demographics
NPI:1578290458
Name:BROCK, WESLEY CARSON (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:WESLEY
Middle Name:CARSON
Last Name:BROCK
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 W TYLER ST
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-3133
Mailing Address - Country:US
Mailing Address - Phone:706-618-9723
Mailing Address - Fax:
Practice Address - Street 1:1710 CLEVELAND HWY
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30721-0664
Practice Address - Country:US
Practice Address - Phone:706-259-9787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-02
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH033776183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist