Provider Demographics
NPI:1619063765
Name:BARNES, MARK TOLLISON (RPH)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:TOLLISON
Last Name:BARNES
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 1:694 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BAXLEY
Mailing Address - State:GA
Mailing Address - Zip Code:31513-0124
Mailing Address - Country:US
Mailing Address - Phone:912-367-2424
Mailing Address - Fax:912-367-4732
Practice Address - Street 1:694 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BAXLEY
Practice Address - State:GA
Practice Address - Zip Code:31513-0124
Practice Address - Country:US
Practice Address - Phone:912-367-2424
Practice Address - Fax:912-367-4732
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH013465183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist