Provider Demographics
NPI:1891370441
Name:MCCULLAR, JONATHAN CADE
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:CADE
Last Name:MCCULLAR
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 1:109 ROGERS ST
Mailing Address - Street 2:
Mailing Address - City:HAZLEHURST
Mailing Address - State:GA
Mailing Address - Zip Code:31539-6601
Mailing Address - Country:US
Mailing Address - Phone:912-347-7053
Mailing Address - Fax:
Practice Address - Street 1:980 W PARKER ST
Practice Address - Street 2:
Practice Address - City:BAXLEY
Practice Address - State:GA
Practice Address - Zip Code:31513-0653
Practice Address - Country:US
Practice Address - Phone:912-367-3234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-16
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH031632183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist