Provider Demographics
NPI:1609019744
Name:FAULK, LAWRENCE R (RPH)
Entity Type:Individual
Prefix:MR
First Name:LAWRENCE
Middle Name:R
Last Name:FAULK
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 1:2489 HAMLIN FLOYD RD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31044-7908
Mailing Address - Country:US
Mailing Address - Phone:478-962-0347
Mailing Address - Fax:
Practice Address - Street 1:2489 HAMLIN FLOYD RD
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:GA
Practice Address - Zip Code:31044-7908
Practice Address - Country:US
Practice Address - Phone:478-962-0347
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-17
Last Update Date:2009-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA018734183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist