Provider Demographics
NPI:1629182530
Name:FORENCE, HAROLD NEAL JR
Entity Type:Individual
Prefix:
First Name:HAROLD
Middle Name:NEAL
Last Name:FORENCE
Suffix:JR
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:PO BOX 791
Mailing Address - Street 2:
Mailing Address - City:LA FAYETTE
Mailing Address - State:GA
Mailing Address - Zip Code:30728-0791
Mailing Address - Country:US
Mailing Address - Phone:706-638-3114
Mailing Address - Fax:706-638-7713
Practice Address - Street 1:324 W PATTON ST
Practice Address - Street 2:
Practice Address - City:LA FAYETTE
Practice Address - State:GA
Practice Address - Zip Code:30728-0791
Practice Address - Country:US
Practice Address - Phone:706-638-3114
Practice Address - Fax:706-638-7713
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11913183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist