Provider Demographics
NPI:1790306330
Name:CANTERBURY, JONATHAN
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:CANTERBURY
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 1:4851 RUSSELL PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-9300
Mailing Address - Country:US
Mailing Address - Phone:478-333-6652
Mailing Address - Fax:
Practice Address - Street 1:4851 RUSSELL PKWY STE 100
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-9300
Practice Address - Country:US
Practice Address - Phone:478-333-6652
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-06
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH019998183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist