Provider Demographics
NPI:1780861872
Name:BAGWELL, EPHYM FREEMAN (RPH)
Entity Type:Individual
Prefix:MR
First Name:EPHYM
Middle Name:FREEMAN
Last Name:BAGWELL
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 1:5100 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-5841
Mailing Address - Country:US
Mailing Address - Phone:706-317-2583
Mailing Address - Fax:706-317-2587
Practice Address - Street 1:5100 RIVER RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-5841
Practice Address - Country:US
Practice Address - Phone:706-317-2583
Practice Address - Fax:706-317-2587
Is Sole Proprietor?:No
Enumeration Date:2008-01-30
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA8967183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist