Provider Demographics
NPI:1659912590
Name:HAND, CARLIS MCKENLEY JR
Entity Type:Individual
Prefix:
First Name:CARLIS
Middle Name:MCKENLEY
Last Name:HAND
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 1:807 LOOP RD APT F1
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30474-7706
Mailing Address - Country:US
Mailing Address - Phone:912-339-3735
Mailing Address - Fax:
Practice Address - Street 1:3109 E 1ST ST
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-8830
Practice Address - Country:US
Practice Address - Phone:912-537-7765
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-02
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH031713183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist