Provider Demographics
NPI:1821656562
Name:THOMPSON, ALEXANDRA SIMONE MCCRACKEN
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:SIMONE MCCRACKEN
Last Name:THOMPSON
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 1:302 E SCREVEN ST
Mailing Address - Street 2:
Mailing Address - City:QUITMAN
Mailing Address - State:GA
Mailing Address - Zip Code:31643-2178
Mailing Address - Country:US
Mailing Address - Phone:229-263-4061
Mailing Address - Fax:229-263-5950
Practice Address - Street 1:19664 VALDOSTA HWY STE A
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-8300
Practice Address - Country:US
Practice Address - Phone:912-223-6326
Practice Address - Fax:229-263-5950
Is Sole Proprietor?:No
Enumeration Date:2019-05-29
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH030997183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist