Provider Demographics
NPI:1811189491
Name:MCCOY, MANDY
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:
Last Name:MCCOY
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 1:6135 ROOSEVELT HWY
Mailing Address - Street 2:
Mailing Address - City:WARM SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:31830-2757
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6135 ROOSEVELT HWY
Practice Address - Street 2:
Practice Address - City:WARM SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:31830-2757
Practice Address - Country:US
Practice Address - Phone:706-655-5422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-16
Last Update Date:2015-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1540183500000X
GARPH025818183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist