Provider Demographics
NPI:1881001733
Name:PATTERSON, CAROL VANDIVER
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:VANDIVER
Last Name:PATTERSON
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 1:4557 MONTCLAIR CIR
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30506-5134
Mailing Address - Country:US
Mailing Address - Phone:770-983-2422
Mailing Address - Fax:
Practice Address - Street 1:662 HIGHWAY 75 S
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:GA
Practice Address - Zip Code:30528-7183
Practice Address - Country:US
Practice Address - Phone:706-219-2309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-11
Last Update Date:2014-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH017418183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist