Provider Demographics
NPI:1639478126
Name:EIDSON, GLORIA JAN T (RPH)
Entity Type:Individual
Prefix:MRS
First Name:GLORIA
Middle Name:JAN T
Last Name:EIDSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:MRS
Other - First Name:JAN
Other - Middle Name:TIPPENS
Other - Last Name:EIDSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:4101 FIVE FORKS TRICKUM RD SW
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-3129
Mailing Address - Country:US
Mailing Address - Phone:770-381-2884
Mailing Address - Fax:770-935-8132
Practice Address - Street 1:4101 FIVE FORKS TRICKUM RD SW
Practice Address - Street 2:
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-3129
Practice Address - Country:US
Practice Address - Phone:770-381-2884
Practice Address - Fax:770-935-8132
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-23
Last Update Date:2011-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA012642183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist