Provider Demographics
NPI:1598236705
Name:WITCHER, MELVIN TREVOR (RPH)
Entity Type:Individual
Prefix:MR
First Name:MELVIN
Middle Name:TREVOR
Last Name:WITCHER
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 1:3215 NORTHBROOK DR
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30341-4627
Mailing Address - Country:US
Mailing Address - Phone:770-356-8639
Mailing Address - Fax:
Practice Address - Street 1:ATLANTA VA MEDICAL CENTER
Practice Address - Street 2:1670 CLAIRMONT ROAD
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033
Practice Address - Country:US
Practice Address - Phone:404-321-6111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA018073183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA018073OtherGEORGIA BOARD OF PHARMACY