Provider Demographics
NPI:1891168654
Name:PHILLIPS, TONY ANTOINE
Entity Type:Individual
Prefix:MR
First Name:TONY
Middle Name:ANTOINE
Last Name:PHILLIPS
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 1:145 OAK KNL
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-4351
Mailing Address - Country:US
Mailing Address - Phone:443-564-0379
Mailing Address - Fax:
Practice Address - Street 1:145 OAK KNL
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4351
Practice Address - Country:US
Practice Address - Phone:443-564-0379
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-02
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA024689183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist