Provider Demographics
NPI:1922361765
Name:CURTIS, MARSHALL
Entity Type:Individual
Prefix:
First Name:MARSHALL
Middle Name:
Last Name:CURTIS
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 1:1520 LANEY WALKER BLVD
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904-5868
Mailing Address - Country:US
Mailing Address - Phone:706-722-7355
Mailing Address - Fax:706-722-5737
Practice Address - Street 1:1520 LANEY WALKER BLVD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-5868
Practice Address - Country:US
Practice Address - Phone:706-722-7355
Practice Address - Fax:706-722-5737
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-18
Last Update Date:2016-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE006386183500000X
GARPH009930183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000323232AMedicaid
GA003125807AMedicaid
GA003125807AMedicaid