Provider Demographics
NPI:1922602085
Name:FARAON, MYRNA CAGALAWAN (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:MYRNA
Middle Name:CAGALAWAN
Last Name:FARAON
Suffix:
Gender:F
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 E GREENE ST
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:GA
Mailing Address - Zip Code:31064-1012
Mailing Address - Country:US
Mailing Address - Phone:706-468-1666
Mailing Address - Fax:
Practice Address - Street 1:330 E GREENE ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:GA
Practice Address - Zip Code:31064-1012
Practice Address - Country:US
Practice Address - Phone:706-468-1666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-29
Last Update Date:2020-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA019860183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist