Provider Demographics
NPI:1821278441
Name:STOREY, CHARLES IVERSON III (RPH)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:IVERSON
Last Name:STOREY
Suffix:III
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:PO BOX A
Mailing Address - Street 2:
Mailing Address - City:PINE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:31822-0500
Mailing Address - Country:US
Mailing Address - Phone:706-663-2255
Mailing Address - Fax:706-663-8026
Practice Address - Street 1:145 N MAIN AVE
Practice Address - Street 2:
Practice Address - City:PINE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:31822-2454
Practice Address - Country:US
Practice Address - Phone:706-663-2255
Practice Address - Fax:706-663-8026
Is Sole Proprietor?:No
Enumeration Date:2007-11-12
Last Update Date:2007-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH010218183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARPH010218OtherSTATE PHARMACIST LICENSE