Provider Demographics
NPI:1760765432
Name:PATTILLO, JASON LAWRENCE (RPH)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:LAWRENCE
Last Name:PATTILLO
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 1:1930 SCENIC HWY N
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-2150
Mailing Address - Country:US
Mailing Address - Phone:770-972-4709
Mailing Address - Fax:770-972-8367
Practice Address - Street 1:1930 SCENIC HWY N
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-2150
Practice Address - Country:US
Practice Address - Phone:770-972-4709
Practice Address - Fax:770-972-8367
Is Sole Proprietor?:No
Enumeration Date:2011-09-20
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH020529183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARPH020529OtherSTATE LICENSE NUMBER