Provider Demographics
NPI:1639779440
Name:UNDERWOOD, LANE
Entity Type:Individual
Prefix:
First Name:LANE
Middle Name:
Last Name:UNDERWOOD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 JOE UNDERWOOD RD
Mailing Address - Street 2:
Mailing Address - City:TWIN CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30471-4214
Mailing Address - Country:US
Mailing Address - Phone:478-494-0670
Mailing Address - Fax:
Practice Address - Street 1:215 N COLEMAN ST
Practice Address - Street 2:
Practice Address - City:SWAINSBORO
Practice Address - State:GA
Practice Address - Zip Code:30401-3530
Practice Address - Country:US
Practice Address - Phone:478-349-8145
Practice Address - Fax:478-237-5060
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-30
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH023938183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist