Provider Demographics
NPI:1659489490
Name:TOOTLE, DANIEL MICHAEL (RPH)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:MICHAEL
Last Name:TOOTLE
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:PO BOX 577
Mailing Address - Street 2:
Mailing Address - City:CLAXTON
Mailing Address - State:GA
Mailing Address - Zip Code:30417-0577
Mailing Address - Country:US
Mailing Address - Phone:912-739-9393
Mailing Address - Fax:912-739-9033
Practice Address - Street 1:305 E LONG ST
Practice Address - Street 2:
Practice Address - City:CLAXTON
Practice Address - State:GA
Practice Address - Zip Code:30417-1411
Practice Address - Country:US
Practice Address - Phone:912-739-9393
Practice Address - Fax:912-739-9033
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA12310183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00745775CMedicaid
GA00745775CMedicaid