Provider Demographics
NPI:1619382892
Name:SPIRES, WAYLON
Entity Type:Individual
Prefix:
First Name:WAYLON
Middle Name:
Last Name:SPIRES
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 1:116 HUCKABEE ST
Mailing Address - Street 2:
Mailing Address - City:MC RAE
Mailing Address - State:GA
Mailing Address - Zip Code:31055-3816
Mailing Address - Country:US
Mailing Address - Phone:229-425-3254
Mailing Address - Fax:
Practice Address - Street 1:116 HUCKABEE ST
Practice Address - Street 2:
Practice Address - City:MC RAE
Practice Address - State:GA
Practice Address - Zip Code:31055-3816
Practice Address - Country:US
Practice Address - Phone:229-425-3254
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-25
Last Update Date:2014-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA025094183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist