Provider Demographics
NPI:1851359061
Name:HENDERSON, EARL R (RPH)
Entity Type:Individual
Prefix:MR
First Name:EARL
Middle Name:R
Last Name:HENDERSON
Suffix:
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 144
Mailing Address - Street 2:
Mailing Address - City:CHULA
Mailing Address - State:GA
Mailing Address - Zip Code:31733-0144
Mailing Address - Country:US
Mailing Address - Phone:229-382-2779
Mailing Address - Fax:
Practice Address - Street 1:220 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:FITZGERALD
Practice Address - State:GA
Practice Address - Zip Code:31750-2438
Practice Address - Country:US
Practice Address - Phone:229-423-0521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2007-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA009881183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist