Provider Demographics
NPI:1619147626
Name:HAWKINS, ETTA LISA (RPH)
Entity Type:Individual
Prefix:MRS
First Name:ETTA
Middle Name:LISA
Last Name:HAWKINS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:386 SIR WINSTON CT
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30238-4561
Mailing Address - Country:US
Mailing Address - Phone:770-477-1458
Mailing Address - Fax:404-657-5461
Practice Address - Street 1:2 PEACHTREE STREET N.E.
Practice Address - Street 2:37TH FLOOR; MEDICAID DIVISION
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30303-3159
Practice Address - Country:US
Practice Address - Phone:404-657-7239
Practice Address - Fax:404-657-5461
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-05
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA13969183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist