Provider Demographics
NPI:1790311785
Name:ALTMAN, CANDACE LANE
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:LANE
Last Name:ALTMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:546 W BACON ST
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE
Mailing Address - State:GA
Mailing Address - Zip Code:31321-4648
Mailing Address - Country:US
Mailing Address - Phone:912-653-1000
Mailing Address - Fax:912-295-4667
Practice Address - Street 1:546 W BACON ST
Practice Address - Street 2:
Practice Address - City:PEMBROKE
Practice Address - State:GA
Practice Address - Zip Code:31321-4648
Practice Address - Country:US
Practice Address - Phone:912-653-1000
Practice Address - Fax:912-295-4667
Is Sole Proprietor?:No
Enumeration Date:2020-03-21
Last Update Date:2020-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH031811183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist