Provider Demographics
NPI:1720012057
Name:LOVVORN, BRANDALL (RPH PHARMD)
Entity Type:Individual
Prefix:MR
First Name:BRANDALL
Middle Name:
Last Name:LOVVORN
Suffix:
Gender:M
Credentials:RPH PHARMD
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 603
Mailing Address - Street 2:
Mailing Address - City:BREMEN
Mailing Address - State:GA
Mailing Address - Zip Code:30110-0603
Mailing Address - Country:US
Mailing Address - Phone:770-537-8889
Mailing Address - Fax:770-537-8817
Practice Address - Street 1:404 ALABAMA AVE S
Practice Address - Street 2:
Practice Address - City:BREMEN
Practice Address - State:GA
Practice Address - Zip Code:30110-2006
Practice Address - Country:US
Practice Address - Phone:770-537-8889
Practice Address - Fax:770-537-8817
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA8702183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00977479AMedicaid
GA00977479AMedicaid