Provider Demographics
NPI:1851979967
Name:JETER, ALISE NICOLE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:ALISE
Middle Name:NICOLE
Last Name:JETER
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1861 ROANOKE RD STE A
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-3850
Mailing Address - Country:US
Mailing Address - Phone:706-350-4200
Mailing Address - Fax:706-350-4220
Practice Address - Street 1:1861 ROANOKE RD STE A
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-3850
Practice Address - Country:US
Practice Address - Phone:706-350-4200
Practice Address - Fax:706-350-4220
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-30
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH029766183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist