Provider Demographics
NPI:1912539206
Name:SMITH, JAMES ALLEN
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:ALLEN
Last Name:SMITH
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 1:3094 WATSON BLVD
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31093-8500
Mailing Address - Country:US
Mailing Address - Phone:478-971-2340
Mailing Address - Fax:478-971-2345
Practice Address - Street 1:3094 WATSON BLVD
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31093-8500
Practice Address - Country:US
Practice Address - Phone:478-971-2340
Practice Address - Fax:478-971-2345
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-05
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0011864183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty