Provider Demographics
NPI:1629528013
Name:DETCHEMENDY, JEREMIAH (RPH)
Entity Type:Individual
Prefix:DR
First Name:JEREMIAH
Middle Name:
Last Name:DETCHEMENDY
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 1:2116 GLENN FLS
Mailing Address - Street 2:
Mailing Address - City:GROVETOWN
Mailing Address - State:GA
Mailing Address - Zip Code:30813-5280
Mailing Address - Country:US
Mailing Address - Phone:706-631-9180
Mailing Address - Fax:
Practice Address - Street 1:2116 GLENN FLS
Practice Address - Street 2:
Practice Address - City:GROVETOWN
Practice Address - State:GA
Practice Address - Zip Code:30813-5280
Practice Address - Country:US
Practice Address - Phone:706-631-9180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-10
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH029535183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist