Provider Demographics
NPI:1619215084
Name:HEADRICK, TROYCE RANDALL
Entity Type:Individual
Prefix:
First Name:TROYCE
Middle Name:RANDALL
Last Name:HEADRICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1635 OLD 41 HWY NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-4480
Mailing Address - Country:US
Mailing Address - Phone:770-426-6860
Mailing Address - Fax:770-426-8495
Practice Address - Street 1:1635 OLD 41 HWY NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-4480
Practice Address - Country:US
Practice Address - Phone:770-426-6860
Practice Address - Fax:770-426-8495
Is Sole Proprietor?:No
Enumeration Date:2013-01-19
Last Update Date:2013-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH011815183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist