Provider Demographics
NPI:1821731902
Name:DOUGLAS, PHILLIP
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2908 OLD US 1
Mailing Address - Street 2:
Mailing Address - City:WADLEY
Mailing Address - State:GA
Mailing Address - Zip Code:30477-4010
Mailing Address - Country:US
Mailing Address - Phone:706-955-5029
Mailing Address - Fax:
Practice Address - Street 1:1308 S HARRIS ST
Practice Address - Street 2:
Practice Address - City:SANDERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:31082-6913
Practice Address - Country:US
Practice Address - Phone:478-552-1988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-18
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0253613336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy