Provider Demographics
NPI:1821139080
Name:CALLAWAY, CHARLES ALLEN (RPH, OD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:ALLEN
Last Name:CALLAWAY
Suffix:
Gender:M
Credentials:RPH, OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2120 HIGHWAY 76 STE A
Mailing Address - Street 2:COHUTTA PLACE PLAZA
Mailing Address - City:CHATSWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30705-7302
Mailing Address - Country:US
Mailing Address - Phone:706-695-0107
Mailing Address - Fax:706-517-9633
Practice Address - Street 1:2120 HIGHWAY 76 STE A
Practice Address - Street 2:COHUTTA PLACE
Practice Address - City:CHATSWORTH
Practice Address - State:GA
Practice Address - Zip Code:30705-7302
Practice Address - Country:US
Practice Address - Phone:706-695-0107
Practice Address - Fax:706-517-9633
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT001074152W00000X
GARPH012110183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1689833089OtherMEDICARE GROUP NPI
GA000667664AMedicaid
GA511G700552OtherMEDICARE PROVIDER PTAN
GAU22220Medicare UPIN