Provider Demographics
NPI:1740790229
Name:ZIMMERMAN, CARLOS M
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:M
Last Name:ZIMMERMAN
Suffix:
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 1:15 TEABERRY TRL
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30132-1153
Mailing Address - Country:US
Mailing Address - Phone:770-334-5714
Mailing Address - Fax:706-622-2752
Practice Address - Street 1:501 E 2ND AVE
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161-3249
Practice Address - Country:US
Practice Address - Phone:706-622-2063
Practice Address - Fax:706-622-2752
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-10
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH022845183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist